Provider Demographics
NPI:1376905943
Name:WICKLUND, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-4824
Mailing Address - Country:US
Mailing Address - Phone:859-655-1195
Mailing Address - Fax:859-655-1194
Practice Address - Street 1:4900 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4824
Practice Address - Country:US
Practice Address - Phone:859-655-1195
Practice Address - Fax:859-655-1194
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY201114472OtherIECE CERTIFICATION