Provider Demographics
NPI:1740338995
Name:NICHOLS, LAURIANNE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURIANNE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5807 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:ENDEAVOR
Mailing Address - State:WI
Mailing Address - Zip Code:53930-9552
Mailing Address - Country:US
Mailing Address - Phone:608-587-2556
Mailing Address - Fax:
Practice Address - Street 1:2450 VINEYARD DR
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-3973
Practice Address - Country:US
Practice Address - Phone:715-342-0290
Practice Address - Fax:715-342-0291
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2738-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39267300Medicaid