Provider Demographics
NPI:1134347792
Name:WICKERT, KIMBERLY MCCRONE (CRC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:MCCRONE
Last Name:WICKERT
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-5613
Mailing Address - Country:US
Mailing Address - Phone:330-722-7695
Mailing Address - Fax:330-722-4572
Practice Address - Street 1:3917 STONEGATE DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-5613
Practice Address - Country:US
Practice Address - Phone:330-722-7695
Practice Address - Fax:330-722-4572
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator