Healthcare Provider Details

I. General information

NPI: 1578178315
Provider Name (Legal Business Name): KRISTA SHABTAIE LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 N MAYFAIR RD STE 101
MILWAUKEE WI
53226-3432
US

IV. Provider business mailing address

933 N MAYFAIR RD STE 101
MILWAUKEE WI
53226-3432
US

V. Phone/Fax

Practice location:
  • Phone: 413-478-8760
  • Fax: 414-249-5443
Mailing address:
  • Phone: 413-478-8760
  • Fax: 414-249-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KRISTA SHABTAIE
Title or Position: SOCIAL WORKER -- OWNER
Credential: LCSW
Phone: 413-478-8760