Healthcare Provider Details

I. General information

NPI: 1134740210
Provider Name (Legal Business Name): AMY C NICHOLSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 HILL ST STE 230
MADISON WI
53705-3539
US

IV. Provider business mailing address

720 HILL ST STE 230
MADISON WI
53705-3539
US

V. Phone/Fax

Practice location:
  • Phone: 608-628-0300
  • Fax:
Mailing address:
  • Phone: 608-628-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7785-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number3172-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: