Healthcare Provider Details

I. General information

NPI: 1750653580
Provider Name (Legal Business Name): KRYSTLE ELIZABETH HAVILAND LPC, CSAC, ICS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 S FAIR OAKS AVE
MADISON WI
53704-5820
US

IV. Provider business mailing address

2413 MIDDLETON BEACH RD
MIDDLETON WI
53562-2910
US

V. Phone/Fax

Practice location:
  • Phone: 608-620-5209
  • Fax:
Mailing address:
  • Phone: 715-781-1653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16489-130
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1238-266
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: