Provider Demographics
NPI:1043826290
Name:NICKERSON, MATTHEW (LMT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 E DOVER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2106
Mailing Address - Country:US
Mailing Address - Phone:719-963-2747
Mailing Address - Fax:
Practice Address - Street 1:100 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1203
Practice Address - Country:US
Practice Address - Phone:414-208-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15019-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist