Provider Demographics
NPI:1154894848
Name:DECORAH, NICHOLE (LPC-IT)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:DECORAH
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1231
Mailing Address - Country:US
Mailing Address - Phone:608-566-5187
Mailing Address - Fax:
Practice Address - Street 1:1508 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1312
Practice Address - Country:US
Practice Address - Phone:608-745-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5176-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154894848Medicaid