Provider Demographics
NPI:1154770865
Name:WICKENHEISER, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WICKENHEISER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 N MESA ST STE E5
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-5820
Mailing Address - Country:US
Mailing Address - Phone:915-345-0499
Mailing Address - Fax:
Practice Address - Street 1:5360 N MESA ST STE E5
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-5820
Practice Address - Country:US
Practice Address - Phone:915-345-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36234961373H00000X
TX134268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist