Provider Demographics
NPI:1992079529
Name:WICKENHAUSER, SHANNON E (BHRS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:WICKENHAUSER
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19608 HARNESS CT
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-3408
Mailing Address - Country:US
Mailing Address - Phone:405-638-5419
Mailing Address - Fax:
Practice Address - Street 1:4149 HIGHLINE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-2103
Practice Address - Country:US
Practice Address - Phone:405-949-1000
Practice Address - Fax:405-949-1063
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid