Healthcare Provider Details

I. General information

NPI: 1356695803
Provider Name (Legal Business Name): KATHRYN DEMIRI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 S HOWELL AVE
OAK CREEK WI
53154-1104
US

IV. Provider business mailing address

3531 W CREST CT
FRANKLIN WI
53132-9333
US

V. Phone/Fax

Practice location:
  • Phone: 414-304-5713
  • Fax: 414-304-5721
Mailing address:
  • Phone: 262-951-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5534-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: