Basic Information
| Provider Information | |||||||||
| NPI: | 1093282683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICKENKAMP | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30180 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300180 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 N MARIO CAPECCHI DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841131103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016621234 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 12625454-4201 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 300021481 | 05 | IN | MEDICAID |