=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083085914
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA DEMUTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2015
-----------------------------------------------------
Last Update Date | 07/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 DAVIS ST
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54015-9788
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-567-9881
-----------------------------------------------------
Fax | 612-520-5821
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KLEIN DR
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54015-9798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-567-9881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 6862-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6862-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------