Provider Demographics
NPI:1861943581
Name:WICKENHEISER, SARA ANN (MED, BCBA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ANN
Last Name:WICKENHEISER
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ANN
Other - Last Name:OGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:2115 SE HOLLAND ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4827
Mailing Address - Country:US
Mailing Address - Phone:915-219-2467
Mailing Address - Fax:
Practice Address - Street 1:1701 MILITARY TRL
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-6330
Practice Address - Country:US
Practice Address - Phone:561-676-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3035103K00000X
UT16-19028106S00000X
FL1-19-35758103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician