Healthcare Provider Details

I. General information

NPI: 1033029491
Provider Name (Legal Business Name): DR NICOLES ONLINE THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2208 SKYLINE DR
WEST BEND WI
53090-1143
US

IV. Provider business mailing address

PO BOX 434
SLINGER WI
53086-0434
US

V. Phone/Fax

Practice location:
  • Phone: 414-232-7277
  • Fax:
Mailing address:
  • Phone: 414-232-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE SMITH
Title or Position: OWNER
Credential: PSYD
Phone: 414-232-7277