Provider Demographics
NPI:1104317221
Name:WICKSTROM, KARI A (AUD)
Entity type:Individual
Prefix:
First Name:KARI
Middle Name:A
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-3507
Mailing Address - Country:US
Mailing Address - Phone:770-334-3062
Mailing Address - Fax:
Practice Address - Street 1:116 MERIDIAN WAY STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2876
Practice Address - Country:US
Practice Address - Phone:859-623-4458
Practice Address - Fax:859-623-4459
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY267988231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist