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General NPI Number Information
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NPI Number | 1043826290
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Entity Type | Individual
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Provider Name | MATTHEW NICKERSON LMT
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Gender | Male
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Dates
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Enumeration Date | 09/22/2020
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Last Update Date | 09/22/2020
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Provider Practice Location Address
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Address Line | 100 W CHESTNUT ST
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City | BURLINGTON
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State | WI
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Zip | 53105-1203
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Country | US
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Telephone | 414-208-4323
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Fax |
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Provider Business Mailing Address
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Address Line | 536 E DOVER ST
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City | MILWAUKEE
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State | WI
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Zip | 53207-2106
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Country | US
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Telephone | 719-963-2747
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 15019-146
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License Number State | WI
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