Provider Demographics
NPI:1659665701
Name:HERDEGEN, NICOLE EVE (ATRL-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:EVE
Last Name:HERDEGEN
Suffix:
Gender:F
Credentials:ATRL-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 W WISCONSIN AVE
Mailing Address - Street 2:STE 2B
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072
Mailing Address - Country:US
Mailing Address - Phone:262-695-8857
Mailing Address - Fax:262-695-8879
Practice Address - Street 1:161 W WISCONSIN AVE
Practice Address - Street 2:STE 2B
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072
Practice Address - Country:US
Practice Address - Phone:262-695-8857
Practice Address - Fax:262-695-8879
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI90-036101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health