Provider Demographics
NPI:1891342101
Name:WICKLI, STEFAN CM (CTRS)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:CM
Last Name:WICKLI
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 NW 23RD BLVD APT 263
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-3062
Mailing Address - Country:US
Mailing Address - Phone:216-308-8207
Mailing Address - Fax:
Practice Address - Street 1:1810 NW 23RD BLVD APT 263
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-3062
Practice Address - Country:US
Practice Address - Phone:216-308-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
82256225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist