Healthcare Provider Details

I. General information

NPI: 1851845978
Provider Name (Legal Business Name): MS. PRATIBHA SRIVASTAVA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PRATIBHA SRIVASTAVA LCSW

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15875 BROOK LN
BROOKFIELD WI
53005-1460
US

IV. Provider business mailing address

15875 BROOK LN
BROOKFIELD WI
53005-1460
US

V. Phone/Fax

Practice location:
  • Phone: 262-527-1359
  • Fax:
Mailing address:
  • Phone: 262-527-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW126924
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15504
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06591300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5735
License Number StateNH
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904020577
License Number StateVA
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8460-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: