Provider Demographics
NPI:1770745655
Name:WICKENBERG, PENNY ANN (MSW)
Entity type:Individual
Prefix:MS
First Name:PENNY
Middle Name:ANN
Last Name:WICKENBERG
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:PENNY
Other - Middle Name:ANN
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:210 S WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-4757
Mailing Address - Country:US
Mailing Address - Phone:406-874-5600
Mailing Address - Fax:
Practice Address - Street 1:210 S WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-4757
Practice Address - Country:US
Practice Address - Phone:406-874-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker