Provider Demographics
NPI:1477107001
Name:VAN WICKLE, RACHEL NADINE (MS TLMFT)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:NADINE
Last Name:VAN WICKLE
Suffix:
Gender:F
Credentials:MS TLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S PARK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9806
Mailing Address - Country:US
Mailing Address - Phone:805-448-7807
Mailing Address - Fax:
Practice Address - Street 1:1754 5TH ST
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-1819
Practice Address - Country:US
Practice Address - Phone:194-931-9351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist