Provider Demographics
NPI:1336655067
Name:WICKLINE, REBECA SUSAN (MA,SLP)
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:SUSAN
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:MA,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22801-4333
Mailing Address - Country:US
Mailing Address - Phone:540-434-3429
Mailing Address - Fax:540-434-4453
Practice Address - Street 1:400 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:HARRISONBURG
Practice Address - State:VA
Practice Address - Zip Code:22801-4333
Practice Address - Country:US
Practice Address - Phone:540-434-3429
Practice Address - Fax:540-434-4453
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007196235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist