Basic Information
| Provider Information | |||||||||
| NPI: | 1578967147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROHUSKA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848164 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530741813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622848164 | ||||||||
| FaxNumber: | 2622848104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2014 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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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 | 104100000X | 826-121 | WI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 826-121 | 01 | WI | LICENSE | OTHER |