Provider Demographics
NPI:1417518812
Name:DE VALK, NICOLE MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DE VALK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3075
Mailing Address - Country:US
Mailing Address - Phone:920-725-1230
Mailing Address - Fax:920-215-6164
Practice Address - Street 1:145 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3075
Practice Address - Country:US
Practice Address - Phone:920-725-1230
Practice Address - Fax:920-215-6164
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1379--124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100090606Medicaid