1275822397 NPI number — MR. NICHOLAS DILLON M.S., M.A., SACIT

Table of content: MR. NICHOLAS DILLON M.S., M.A., SACIT (NPI 1275822397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275822397 NPI number — MR. NICHOLAS DILLON M.S., M.A., SACIT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLON
Provider First Name:
NICHOLAS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S., M.A., SACIT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275822397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3815 N BROOKFIELD RD
Provider Second Line Business Mailing Address:
SUITE 104-141
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-1964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-305-9818
Provider Business Mailing Address Fax Number:
262-691-4966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1177 QUAIL CT
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
PEWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53072-3790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-691-2980
Provider Business Practice Location Address Fax Number:
262-691-4966
Provider Enumeration Date:
03/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  16137-131 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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