Provider Demographics
NPI:1619435294
Name:WICKLUND, SHELLY MARIE (RBT-18-56792)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:MARIE
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:RBT-18-56792
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:738 ARMY TRAIL RD.
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188
Mailing Address - Country:US
Mailing Address - Phone:630-473-8648
Mailing Address - Fax:
Practice Address - Street 1:738 ARMY TRAIL RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188
Practice Address - Country:US
Practice Address - Phone:630-473-8648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-03
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-56792106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician