Provider Demographics
NPI:1669962825
Name:THULL, NICOLE SHANNON (SAC-IT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHANNON
Last Name:THULL
Suffix:
Gender:F
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9349 WINDY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9742
Mailing Address - Country:US
Mailing Address - Phone:262-483-4870
Mailing Address - Fax:
Practice Address - Street 1:1421 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9136
Practice Address - Country:US
Practice Address - Phone:262-626-4166
Practice Address - Fax:262-626-8431
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17291-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)