Provider Demographics
NPI:1861087439
Name:SEGLAH, KRISTINA L (CADC-II)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:SEGLAH
Suffix:
Gender:F
Credentials:CADC-II
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:L
Other - Last Name:FONTAINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CADC-II
Mailing Address - Street 1:412 S. ANDREWS ST.
Mailing Address - Street 2:1/2
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166
Mailing Address - Country:US
Mailing Address - Phone:971-400-8150
Mailing Address - Fax:
Practice Address - Street 1:412 S ANDREWS ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2902
Practice Address - Country:US
Practice Address - Phone:971-770-2728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHA-I-003390101YM0800X
OR23-08-20313101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health