Provider Demographics
NPI:1972279594
Name:WICKER, TARYN RENAE (MA CF-SLP)
Entity Type:Individual
Prefix:MISS
First Name:TARYN
Middle Name:RENAE
Last Name:WICKER
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 N RESEARCH DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-8835
Mailing Address - Country:US
Mailing Address - Phone:419-354-9010
Mailing Address - Fax:
Practice Address - Street 1:28090 LEMOYNE RD
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:OH
Practice Address - Zip Code:43447-9747
Practice Address - Country:US
Practice Address - Phone:419-661-6660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20211756-SP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist