Provider Demographics
NPI:1063857365
Name:GOEHRE, NICOLE M (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GOEHRE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-6336
Mailing Address - Country:US
Mailing Address - Phone:757-469-4250
Mailing Address - Fax:
Practice Address - Street 1:316 N MILWAUKEE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5885
Practice Address - Country:US
Practice Address - Phone:414-615-0665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5323-26174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist