Provider Demographics
NPI:1346794344
Name:BORRESON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BORRESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23062 WHITEHALL RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:WI
Mailing Address - Zip Code:54747-9065
Mailing Address - Country:US
Mailing Address - Phone:715-985-3452
Mailing Address - Fax:
Practice Address - Street 1:23062 WHITEHALL RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:WI
Practice Address - Zip Code:54747-9065
Practice Address - Country:US
Practice Address - Phone:715-985-3452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)