Provider Demographics
NPI:1104678325
Name:WICKMAN, VERONICA (COTAL)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51610 WASHINGTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6614
Mailing Address - Country:US
Mailing Address - Phone:810-580-8251
Mailing Address - Fax:
Practice Address - Street 1:5635 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-2817
Practice Address - Country:US
Practice Address - Phone:810-385-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202009866224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant