Provider Demographics
NPI:1851073480
Name:WICKE, ABIGAIL MARIE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:MARIE
Last Name:WICKE
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 1:2415 TREGARON AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2673
Mailing Address - Country:US
Mailing Address - Phone:502-855-2006
Mailing Address - Fax:
Practice Address - Street 1:10216 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-3616
Practice Address - Country:US
Practice Address - Phone:502-267-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist