Provider Demographics
NPI:1386188712
Name:NICKLAUS, CHRISTINE MARIE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:NICKLAUS
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 1:1557 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3920
Mailing Address - Country:US
Mailing Address - Phone:715-732-6868
Mailing Address - Fax:715-732-6867
Practice Address - Street 1:1557 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3920
Practice Address - Country:US
Practice Address - Phone:715-732-6868
Practice Address - Fax:715-732-6867
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2992226101YP2500X
WI6937125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033659271OtherORGANIZATION NPI