Provider Demographics
NPI:1356695803
Name:DEMIRI, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:DEMIRI
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 1:3531 W CREST CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9333
Mailing Address - Country:US
Mailing Address - Phone:262-951-8480
Mailing Address - Fax:
Practice Address - Street 1:6416 S HOWELL AVE
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1104
Practice Address - Country:US
Practice Address - Phone:414-304-5713
Practice Address - Fax:414-304-5721
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5534-125101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100026714Medicaid
WI100026714Medicaid