Provider Demographics
NPI:1639110398
Name:ISHATOVA, CIEL (LCSW, LMFT)
Entity Type:Individual
Prefix:MS
First Name:CIEL
Middle Name:
Last Name:ISHATOVA
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:LYNN
Other - Last Name:GOLDSTONE-HOPKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4704 WINNEQUAH RD
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-2030
Mailing Address - Country:US
Mailing Address - Phone:608-255-9330
Mailing Address - Fax:608-255-7810
Practice Address - Street 1:1619 MONROE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2063
Practice Address - Country:US
Practice Address - Phone:608-255-9330
Practice Address - Fax:608-255-7810
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2248-1231041C0700X
WI261-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39255100Medicaid
WI39255100Medicaid