Provider Demographics
NPI:1578064101
Name:WICKODA, ERICA (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:WICKODA
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:WICKSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 E 48TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5651
Mailing Address - Country:US
Mailing Address - Phone:612-412-1453
Mailing Address - Fax:
Practice Address - Street 1:4305 41ST AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-4037
Practice Address - Country:US
Practice Address - Phone:612-412-1453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN296041041C0700X
WASC608322951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical