MEDICARE: NICOLE DASYA NORCROSS MSW CAPSW

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	1041C0700X	Clinical Social Worker	9787-123

General Provider Information

NPI Number	:	1518507235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DASYA NORCROSS MSW CAPSW

Provider Business Mailing Address
First Line	:	PO BOX 22040
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54305-2040
Country	:	US
Telephone Number	:	920-445-7222
Fax Number	:	920-445-7289

Provider Business Practice Location Address
First Line	:	1710 LAWRENCE DR STE 200
Second Line	:
City	:	DE PERE
State	:	WI
Zip	:	54115-9195
Country	:	US
Telephone Number	:	920-364-9078
Fax Number	:

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

Provider Enumeration Date	:	01/10/2020
Last Update Date	:	12/23/2021

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