Provider Demographics
NPI:1669602413
Name:DOERR, KRISTA L (LPC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:L
Last Name:DOERR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 ANNEX RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:WI
Mailing Address - Zip Code:53549-9803
Mailing Address - Country:US
Mailing Address - Phone:920-674-8190
Mailing Address - Fax:920-674-6113
Practice Address - Street 1:1541 ANNEX RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9803
Practice Address - Country:US
Practice Address - Phone:920-674-8190
Practice Address - Fax:920-674-6113
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3826-125101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669602413Medicaid