Provider Demographics
NPI:1255634226
Name:WICKSTROM, STEPHANIE (LAT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:JENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT
Mailing Address - Street 1:1400 BELLINGER ST.
Mailing Address - Street 2:P.O. BOX1510
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-6453
Mailing Address - Fax:
Practice Address - Street 1:1400 BELLINGER ST.
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54702-1510
Practice Address - Country:US
Practice Address - Phone:715-838-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-14
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1078-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer