Provider Demographics
NPI:1851643266
Name:WICKWIRE, EDWARD (LMT)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:WICKWIRE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 SW OAK ST STE 209
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2805
Mailing Address - Country:US
Mailing Address - Phone:503-702-3151
Mailing Address - Fax:
Practice Address - Street 1:917 SW OAK ST STE 209
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2805
Practice Address - Country:US
Practice Address - Phone:503-702-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist