Provider Demographics
NPI:1992016935
Name:WICKERT, EMILY ANN (SLP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANN
Last Name:WICKERT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANN
Other - Last Name:SOLCHENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:840 APHRODITE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-5460
Mailing Address - Country:US
Mailing Address - Phone:920-433-5555
Mailing Address - Fax:920-430-4745
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301
Practice Address - Country:US
Practice Address - Phone:920-431-5555
Practice Address - Fax:920-430-4745
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3362-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100009898Medicaid