Provider Demographics
NPI:1063887560
Name:WICKERAAD, KARA (DPT, ATC)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:WICKERAAD
Suffix:
Gender:F
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 ROSECRANS ST STE F
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-4831
Mailing Address - Country:US
Mailing Address - Phone:619-223-7175
Mailing Address - Fax:
Practice Address - Street 1:3145 ROSECRANS ST STE F
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-4831
Practice Address - Country:US
Practice Address - Phone:619-223-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist