Basic Information
| Provider Information | |||||||||
| NPI: | 1518188549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUDEK | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 TOWER DR | ||||||||
| Address2: | |||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088253008 | ||||||||
| FaxNumber: | 6088253794 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 TOWER DR | ||||||||
| Address2: | |||||||||
| City: | SUN PRAIRIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535901239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088253008 | ||||||||
| FaxNumber: | 6088253794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 10/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 3283 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 61086 | 01 | WI | DEAN HEALTH INSURANCE | OTHER | 40937000 | 05 | WI | MEDICAID |