Provider Demographics
NPI:1033443122
Name:ROTHONG, NICHELLE D (PHD)
Entity Type:Individual
Prefix:MS
First Name:NICHELLE
Middle Name:D
Last Name:ROTHONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-385-1922
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-385-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI764-226101Y00000X
WI3383103T00000X
WI3383-57103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist