Healthcare Provider Details

I. General information

NPI: 1962946095
Provider Name (Legal Business Name): TINA STASZAK LPC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5235 N IRONWOOD RD
GLENDALE WI
53217-4906
US

IV. Provider business mailing address

5235 N IRONWOOD RD
GLENDALE WI
53217-4906
US

V. Phone/Fax

Practice location:
  • Phone: 414-902-1519
  • Fax:
Mailing address:
  • Phone: 414-902-1519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7063-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17478-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: