Provider Demographics
NPI:1497319743
Name:STOTZHEIM, NICOLE A (BCBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:STOTZHEIM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:A
Other - Last Name:RADUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 FOURIER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1969
Mailing Address - Country:US
Mailing Address - Phone:608-662-9327
Mailing Address - Fax:608-662-9041
Practice Address - Street 1:1141 W MAIN AVE STE 201
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-1695
Practice Address - Country:US
Practice Address - Phone:920-338-1610
Practice Address - Fax:920-338-1616
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI289-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst