Provider Demographics
NPI:1700127305
Name:WICKSTROM, EMILY (MA, CCC-SLP/L)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:MA, CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 N ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 S BLOOMINGDALE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-1493
Practice Address - Country:US
Practice Address - Phone:630-351-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist