Provider Demographics
NPI:1558780056
Name:DOUGHTY, KRISTA (1383-26)
Entity Type:Individual
Prefix:MS
First Name:KRISTA
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:1383-26
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 W VLIET ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-2117
Mailing Address - Country:US
Mailing Address - Phone:414-289-6090
Mailing Address - Fax:414-226-4184
Practice Address - Street 1:1220 W VLIET ST
Practice Address - Street 2:SUITE 304
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2117
Practice Address - Country:US
Practice Address - Phone:414-289-6090
Practice Address - Fax:414-226-4184
Is Sole Proprietor?:No
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1383-26101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional