Healthcare Provider Details

I. General information

NPI: 1619660065
Provider Name (Legal Business Name): NICHOLAS SALAZAR LPC, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 N GREEN BAY AVE STE 205
GLENDALE WI
53209-4446
US

IV. Provider business mailing address

2582 N CRAMER ST APT 4
MILWAUKEE WI
53211-3990
US

V. Phone/Fax

Practice location:
  • Phone: 262-789-1191
  • Fax:
Mailing address:
  • Phone: 262-664-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10389-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: