Provider Demographics
NPI:1295472959
Name:WICKSTROM, RACHEL D (LADC)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:D
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 GRAHAM LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MN
Mailing Address - Zip Code:55749-9519
Mailing Address - Country:US
Mailing Address - Phone:218-391-2508
Mailing Address - Fax:
Practice Address - Street 1:332 W SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1808
Practice Address - Country:US
Practice Address - Phone:218-722-4379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300551101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)