Provider Demographics
NPI:1417341082
Name:WICKIZER, REBECCA (OTR/L)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WICKIZER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 E SKELLY DR
Mailing Address - Street 2:SUITE 402
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5800 E SKELLY DR
Practice Address - Street 2:SUITE 402
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6471
Practice Address - Country:US
Practice Address - Phone:918-351-4596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1955225X00000X
VA0119006285225X00000X
CO0004236225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist