Provider Demographics
NPI:1336398767
Name:RANDERSON, NICHOLE M (BS, MA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
Last Name:RANDERSON
Suffix:
Gender:F
Credentials:BS, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W SPENCER ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-4015
Mailing Address - Country:US
Mailing Address - Phone:920-735-9010
Mailing Address - Fax:920-735-9050
Practice Address - Street 1:4000 W SPENCER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-4015
Practice Address - Country:US
Practice Address - Phone:920-735-9010
Practice Address - Fax:920-735-9050
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)