Provider Demographics
NPI:1285369108
Name:WICKBERG, KASEY LYNN (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:LYNN
Last Name:WICKBERG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:LYNN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14805 MOON DAISY DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1466
Mailing Address - Country:US
Mailing Address - Phone:918-527-5360
Mailing Address - Fax:
Practice Address - Street 1:14715 BRISTOL PARK BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1894
Practice Address - Country:US
Practice Address - Phone:405-840-1686
Practice Address - Fax:405-840-1006
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist