Provider Demographics
NPI:1407342405
Name:WIKSTROM, PIA (SLP)
Entity Type:Individual
Prefix:DR
First Name:PIA
Middle Name:
Last Name:WIKSTROM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W END AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3538
Mailing Address - Country:US
Mailing Address - Phone:917-573-5798
Mailing Address - Fax:
Practice Address - Street 1:900 W END AVE APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3538
Practice Address - Country:US
Practice Address - Phone:917-573-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005638-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty