Provider Demographics
NPI:1043698897
Name:NICHOLSON, SUSAN JENNIFER (BCBA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JENNIFER
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:JENNIFER
Other - Last Name:ANKROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N27W23953 PAUL RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6242
Mailing Address - Country:US
Mailing Address - Phone:262-347-0701
Mailing Address - Fax:262-347-0705
Practice Address - Street 1:N27W23953 PAUL RD
Practice Address - Street 2:SUITE 206
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6242
Practice Address - Country:US
Practice Address - Phone:262-347-0701
Practice Address - Fax:262-347-0705
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst