Provider Demographics
NPI:1780032607
Name:OLSON, NICOLE (LCSW, CSAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1813
Mailing Address - Country:US
Mailing Address - Phone:262-284-8142
Mailing Address - Fax:262-284-8104
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1813
Practice Address - Country:US
Practice Address - Phone:262-284-8142
Practice Address - Fax:262-284-8104
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16319-132101YA0400X
WI9135-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)