Healthcare Provider Details

I. General information

NPI: 1801739701
Provider Name (Legal Business Name): NICHOLAS GREEN LPC, CRC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E VERONA AVE # 1075
VERONA WI
53593-1223
US

IV. Provider business mailing address

200 E VERONA AVE # 1075
VERONA WI
53593-1223
US

V. Phone/Fax

Practice location:
  • Phone: 608-891-1526
  • Fax:
Mailing address:
  • Phone: 608-891-1526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12277-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12277-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: