Healthcare Provider Details

I. General information

NPI: 1619803723
Provider Name (Legal Business Name): NICHOLAS JEFFREY WALKOWIAK MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 N PORT WASHINGTON RD STE 300
GLENDALE WI
53217-4928
US

IV. Provider business mailing address

2129 N STOUGHTON RD
MADISON WI
53704-2613
US

V. Phone/Fax

Practice location:
  • Phone: 218-590-3590
  • Fax:
Mailing address:
  • Phone: 218-590-3590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberSTUDENT
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: