Provider Demographics
NPI:1992040570
Name:WICKENHAUSER, BARBARA J
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:J
Last Name:WICKENHAUSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1403
Mailing Address - Country:US
Mailing Address - Phone:631-235-1767
Mailing Address - Fax:
Practice Address - Street 1:119 ALDEN DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1403
Practice Address - Country:US
Practice Address - Phone:631-235-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator