Provider Demographics
NPI:1033322789
Name:WIKANDER, MARY TERESA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:TERESA
Last Name:WIKANDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:M
Other - Last Name:WIKANDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005
Mailing Address - Country:US
Mailing Address - Phone:503-539-2843
Mailing Address - Fax:
Practice Address - Street 1:120 SO ELLIOTT RD
Practice Address - Street 2:STE 200
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:503-539-2843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL37021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical