Provider Demographics
NPI:1699457275
Name:WICKENHOFER, CHARLES (LSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:WICKENHOFER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 KIMS ST
Mailing Address - Street 2:
Mailing Address - City:ELSMERE
Mailing Address - State:KY
Mailing Address - Zip Code:41018-2196
Mailing Address - Country:US
Mailing Address - Phone:513-446-3287
Mailing Address - Fax:
Practice Address - Street 1:5050 MADISON RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-1491
Practice Address - Country:US
Practice Address - Phone:513-272-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2309462104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker