Provider Demographics
NPI:1144708942
Name:NICKLES COUNSELING, LLC
Entity type:Organization
Organization Name:NICKLES COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:VENETA
Authorized Official - Last Name:NICKLES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-256-5115
Mailing Address - Street 1:401 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-1487
Mailing Address - Country:US
Mailing Address - Phone:608-256-5115
Mailing Address - Fax:608-256-5116
Practice Address - Street 1:401 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1487
Practice Address - Country:US
Practice Address - Phone:608-256-5115
Practice Address - Fax:608-256-5116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2843-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780138776Medicaid