Doctor Name: | MR. MICHAEL R NICHOLSON |
NPI Number: | 1619101847 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | CSAC CSIT |
License Number: | 15466-132 |
Business Practice Address: | 10940 W Forest Home Ave Hales Corners, WI - 531302516 |
Business Phone Number: | 2622784462 |
Business Fax Number: | 8153872569 |
Mailing Address: | 1021 N Mulford Rd, ROCKFORD |
State: | IL |
Postal Code: | 611073877 |
Phone Number: | 8153915600 |
Fax Number: | 8153164726 |
NPI Enumeration Date: | 05/01/2009 |
NPI Last Update Date: | 04/26/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | 15466-132 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |