Provider Demographics
NPI:1851845978
Name:SRIVASTAVA, PRATIBHA
Entity Type:Individual
Prefix:MS
First Name:PRATIBHA
Middle Name:
Last Name:SRIVASTAVA
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:PRATIBHA
Other - Middle Name:
Other - Last Name:SRIVASTAVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:15875 BROOK LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-1460
Mailing Address - Country:US
Mailing Address - Phone:262-527-1359
Mailing Address - Fax:
Practice Address - Street 1:7635 W OKLAHOMA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53219-3600
Practice Address - Country:US
Practice Address - Phone:414-301-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8460-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical