Provider Demographics
NPI:1962946095
Name:STASZAK, TINA (LPC-IT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:STASZAK
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5235 N IRONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4906
Mailing Address - Country:US
Mailing Address - Phone:414-902-1519
Mailing Address - Fax:
Practice Address - Street 1:5235 N IRONWOOD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4906
Practice Address - Country:US
Practice Address - Phone:414-902-1519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3348-226101YM0800X
WI17478-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)