Provider Demographics
NPI:1386781748
Name:WICHERT, CHARLENE M (MA CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:M
Last Name:WICHERT
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 E RANDOLPH AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-4670
Mailing Address - Country:US
Mailing Address - Phone:580-234-3734
Mailing Address - Fax:580-234-3554
Practice Address - Street 1:2615 E RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4670
Practice Address - Country:US
Practice Address - Phone:580-234-3734
Practice Address - Fax:580-234-3554
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2181235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100662450AMedicaid