Provider Demographics
NPI:1104901263
Name:JOHNSON, NICOLE (LPC,LMFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPC,LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 GREEN BAY RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-2926
Mailing Address - Country:US
Mailing Address - Phone:262-654-8366
Mailing Address - Fax:
Practice Address - Street 1:6121 GREEN BAY RD
Practice Address - Street 2:SUITE 230
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2926
Practice Address - Country:US
Practice Address - Phone:262-654-8366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2882-125101YM0800X
WI635-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist