Provider Demographics
NPI:1952069866
Name:NIKODEM, PAMELA JANE (LPC-T, SAC-T)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JANE
Last Name:NIKODEM
Suffix:
Gender:F
Credentials:LPC-T, SAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-1594
Mailing Address - Country:US
Mailing Address - Phone:920-404-4638
Mailing Address - Fax:920-632-4315
Practice Address - Street 1:2920 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-1594
Practice Address - Country:US
Practice Address - Phone:920-404-4638
Practice Address - Fax:920-632-4315
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19515-130101YA0400X
WI5078-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)