Provider Demographics
NPI:1740636364
Name:WICHMANN, STEPHANIE MARA (MSW, LCSW/LICSW)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MARA
Last Name:WICHMANN
Suffix:
Gender:F
Credentials:MSW, LCSW/LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 OFFICERS ROW
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-3849
Mailing Address - Country:US
Mailing Address - Phone:360-838-3356
Mailing Address - Fax:360-326-1877
Practice Address - Street 1:951 OFFICERS ROW
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3849
Practice Address - Country:US
Practice Address - Phone:360-838-3356
Practice Address - Fax:360-326-1877
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-12
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL132251041C0700X
WALW601882241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500814577Medicaid