Healthcare Provider Details

I. General information

NPI: 1356253066
Provider Name (Legal Business Name): NICOLE MCGUIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S MAIN ST
FONTANA WI
53125-1232
US

IV. Provider business mailing address

450 S MAIN ST
FONTANA WI
53125-1232
US

V. Phone/Fax

Practice location:
  • Phone: 262-275-6881
  • Fax:
Mailing address:
  • Phone: 262-275-6881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number864927
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: