Healthcare Provider Details

I. General information

NPI: 1033443122
Provider Name (Legal Business Name): NICHELLE D ROTHONG PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2009
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 W KINNICKINNIC RIVER PKWY
MILWAUKEE WI
53215-3669
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-385-1922
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3383
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number3383-57
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number764-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: