Provider Demographics
NPI:1356311393
Name:WICKERING, CHARLENE (LMSW ACS)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:WICKERING
Suffix:
Gender:F
Credentials:LMSW ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30516 DEPT 6000A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-8016
Mailing Address - Country:US
Mailing Address - Phone:616-942-8060
Mailing Address - Fax:616-942-6690
Practice Address - Street 1:3330 CLAYSTONE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7716
Practice Address - Country:US
Practice Address - Phone:616-942-8060
Practice Address - Fax:616-942-6690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020614191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical