Healthcare Provider Details

I. General information

NPI: 1093226466
Provider Name (Legal Business Name): NICOLE MARIE WITEK MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 E 1ST ST
FOND DU LAC WI
54935-4505
US

IV. Provider business mailing address

459 E 1ST ST
FOND DU LAC WI
54935-4505
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-3500
  • Fax: 920-929-3129
Mailing address:
  • Phone: 920-929-3500
  • Fax: 920-929-3129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20243-130
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number136394-121
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: