Basic Information
Provider Information | |||||||||
NPI: | 1679725972 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEMIANIUK | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THIELE | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | W175N11120 STONEWOOD DR | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | WI | ||||||||
PostalCode: | 530226511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623455560 | ||||||||
FaxNumber: | 2623455531 | ||||||||
Practice Location | |||||||||
Address1: | 4351 W COLLEGE AVE STE 410 | ||||||||
Address2: |   | ||||||||
City: | APPLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 549143928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004381772 | ||||||||
FaxNumber: | 2623455562 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2008 | ||||||||
LastUpdateDate: | 10/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 819-124 | WI | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1679725972 | 05 | WI |   | MEDICAID |