Provider Demographics
NPI:1689616518
Name:JOHNSON, NICOLE RENE (MS, LPC, SAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MS, LPC, SAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENE
Other - Last Name:HANSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:704 SAND LAKE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-2456
Mailing Address - Country:US
Mailing Address - Phone:608-799-3881
Mailing Address - Fax:608-440-2823
Practice Address - Street 1:704 SAND LAKE RD STE 105
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-2456
Practice Address - Country:US
Practice Address - Phone:608-799-3881
Practice Address - Fax:608-440-2823
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15560-131101YA0400X
WI3067-125101YM0800X, 101YP2500X
WI15560101YP2500X
WI3067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40907500Medicaid