Provider Demographics
NPI:1457686073
Name:WICKHAM, RAINA
Entity Type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:WICKHAM
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 1:24971 BLUEROCK LN
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-9554
Mailing Address - Country:US
Mailing Address - Phone:541-609-1305
Mailing Address - Fax:541-714-3770
Practice Address - Street 1:1229 MAIN STREET, SUITE 105
Practice Address - Street 2:
Practice Address - City:PHILOMATH
Practice Address - State:OR
Practice Address - Zip Code:97370
Practice Address - Country:US
Practice Address - Phone:541-609-1305
Practice Address - Fax:541-714-3770
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11-12-75101YA0400X
ORMASTERS - PSU101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500658765Medicaid