Provider Demographics
NPI:1457115172
Name:MUSKEVITSCH, NICOLLE MADISON (MSW, SAC-IT)
Entity Type:Individual
Prefix:MS
First Name:NICOLLE
Middle Name:MADISON
Last Name:MUSKEVITSCH
Suffix:
Gender:F
Credentials:MSW, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2970
Mailing Address - Country:US
Mailing Address - Phone:920-419-6480
Mailing Address - Fax:
Practice Address - Street 1:121 S WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1740
Practice Address - Country:US
Practice Address - Phone:920-419-6480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI797859101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)