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NPI Code Detail

MEDICARE: MS. NICOLE VIENNA GUSTAFSON L.P.C.

MEDICARE: MS. NICOLE VIENNA GUSTAFSON L.P.C.
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
1101YP2500XProfessional Counselor4197-125WI

General Provider Information

NPI Number : 1790916278
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. NICOLE VIENNA GUSTAFSON L.P.C.
Provider Business Mailing Address
First Line : 4601 LAKE MEADOW DR
Second Line :
City : WIND POINT
State : WI
Zip : 53402-5319
Country : US
Telephone Number : 414-899-3177
Fax Number :
Provider Business Practice Location Address
First Line : 4109 67TH ST
Second Line :
City : KENOSHA
State : WI
Zip : 53142-3836
Country : US
Telephone Number : 262-652-9830
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2009
Last Update Date : 06/04/2026

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