Provider Demographics
NPI:1659546422
Name:WICKENHAUSER, HOLLY D (ATC)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:D
Last Name:WICKENHAUSER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LN
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8111
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-663-5711
Practice Address - Street 1:1111 TRINITY LN
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8111
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-663-5711
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0018912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer