Provider Demographics
NPI:1619698545
Name:HOLDER, NICOLE C (MS, LPC-IT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:HOLDER
Suffix:
Gender:F
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0301
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-742-4087
Practice Address - Street 1:1221 INNOVATION DR STE 221
Practice Address - Street 2:
Practice Address - City:WHITEWATER
Practice Address - State:WI
Practice Address - Zip Code:53190-1483
Practice Address - Country:US
Practice Address - Phone:262-473-0670
Practice Address - Fax:608-268-9780
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health