MEDICARE: CHRISTINE MARIE NICKLAUS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	2992226	WI
2	101YP2500X	Professional Counselor	6937125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1033659271	OTHER		ORGANIZATION NPI

General Provider Information

NPI Number	:	1386188712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE MARIE NICKLAUS

Provider Business Mailing Address
First Line	:	1557 CLEVELAND AVE
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-3920
Country	:	US
Telephone Number	:	715-732-6868
Fax Number	:	715-732-6867

Provider Business Practice Location Address
First Line	:	1557 CLEVELAND AVE
Second Line	:
City	:	MARINETTE
State	:	WI
Zip	:	54143-3920
Country	:	US
Telephone Number	:	715-732-6868
Fax Number	:	715-732-6867

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2016
Last Update Date	:	10/06/2020

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