Provider Demographics
NPI:1922791862
Name:LY, WICHIKA TE
Entity Type:Individual
Prefix:
First Name:WICHIKA
Middle Name:TE
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WICHIKA
Other - Middle Name:TE
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1496 JASMINE CIR
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2921
Practice Address - Country:US
Practice Address - Phone:415-497-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician