Basic Information
Provider Information | |||||||||
NPI: | 1902479470 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OELHAFEN | ||||||||
FirstName: | KRISTA | ||||||||
MiddleName: | LAUREN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1230 CORPORATE CENTER DR STE 100 | ||||||||
Address2: |   | ||||||||
City: | OCONOMOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 530664883 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2627891191 | ||||||||
FaxNumber: | 2628216180 | ||||||||
Practice Location | |||||||||
Address1: | 11518 N PORT WASHINGTON RD STE 202 | ||||||||
Address2: |   | ||||||||
City: | MEQUON | ||||||||
State: | WI | ||||||||
PostalCode: | 530923443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2622446178 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2021 | ||||||||
LastUpdateDate: | 07/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/12/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 9795-123 | WI | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X |   | WI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 9795-123 | WI | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 1041C0700X | 01 | WI | TAXONOMY | OTHER |