Provider Demographics
NPI:1790294718
Name:BOWER, NIKOLE RENEE
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:RENEE
Last Name:BOWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NIKOLE
Other - Middle Name:RENEE
Other - Last Name:TREIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4929 W FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2324
Mailing Address - Country:US
Mailing Address - Phone:414-871-6122
Mailing Address - Fax:414-871-6122
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:904-396-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI132184-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker