Provider Demographics
NPI:1013482587
Name:SHABTAIE, KRISTA (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:SHABTAIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:
Other - Last Name:MEYERHOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:2218 W ROCHELLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2724
Mailing Address - Country:US
Mailing Address - Phone:413-478-8760
Mailing Address - Fax:
Practice Address - Street 1:933 N MAYFAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3432
Practice Address - Country:US
Practice Address - Phone:413-478-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8981-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical