Provider Demographics
NPI:1639545023
Name:WIENKES, NICHOL
Entity Type:Individual
Prefix:
First Name:NICHOL
Middle Name:
Last Name:WIENKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICHOL
Other - Middle Name:
Other - Last Name:GRATHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-8630
Mailing Address - Country:US
Mailing Address - Phone:920-294-4070
Mailing Address - Fax:920-294-4139
Practice Address - Street 1:571 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-8630
Practice Address - Country:US
Practice Address - Phone:920-294-4070
Practice Address - Fax:920-294-4139
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16805-130101YA0400X
WI5942-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100047842Medicaid