Individual
NICOLE SHANNON THULL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
SAC-IT
Contact information
Practice address
1421 FOND DU LAC AVE, KEWASKUM, WI 53040-9136
(262) 626-4166
(262) 626-8431
Mailing address
9349 WINDY ACRES DR, KEWASKUM, WI 53040-9742
(262) 483-4870
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
17291-130
WI
Other
Enumeration date
05/14/2018
Last updated
05/14/2018
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