Provider Demographics
NPI:1902479470
Name:OELHAFEN, KRISTA LAUREN (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:LAUREN
Last Name:OELHAFEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 CORPORATE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4883
Mailing Address - Country:US
Mailing Address - Phone:262-789-1191
Mailing Address - Fax:262-821-6180
Practice Address - Street 1:11518 N PORT WASHINGTON RD STE 202
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3443
Practice Address - Country:US
Practice Address - Phone:262-244-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9795-123101YP2500X, 1041C0700X
WI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1041C0700XOtherTAXONOMY