Provider Demographics
NPI:1679725972
Name:DEMIANIUK, MEGAN J (MS)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:J
Last Name:DEMIANIUK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:J
Other - Last Name:THIELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:W175N11120 STONEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-6511
Mailing Address - Country:US
Mailing Address - Phone:262-345-5560
Mailing Address - Fax:262-345-5531
Practice Address - Street 1:4351 W COLLEGE AVE STE 410
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-3928
Practice Address - Country:US
Practice Address - Phone:800-438-1772
Practice Address - Fax:262-345-5562
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI819-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679725972Medicaid
MIL1878922OtherSTATE LICENSE