Provider Demographics
NPI:1134666514
Name:BICKHAM, NICOLE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:BICKHAM
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 1:661 LAVERNE DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5931
Mailing Address - Country:US
Mailing Address - Phone:414-858-8085
Mailing Address - Fax:414-395-4627
Practice Address - Street 1:1035 W GLEN OAKS LN STE 204
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3395
Practice Address - Country:US
Practice Address - Phone:414-858-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3577-57103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist