Provider Demographics
NPI:1154077337
Name:KOSHATKA, ELIZABETH ROSE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROSE
Last Name:KOSHATKA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 E HIDDEN CREEK CT APT 202
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-4485
Mailing Address - Country:US
Mailing Address - Phone:563-419-2903
Mailing Address - Fax:
Practice Address - Street 1:1849 N DOCTOR M.L.K. JR DR
Practice Address - Street 2:#102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212
Practice Address - Country:US
Practice Address - Phone:414-347-1774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor