Basic Information
| Provider Information | |||||||||
| NPI: | 1942230842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKERT | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 406153 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303841876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614788770 | ||||||||
| FaxNumber: | 5616888877 | ||||||||
| Practice Location | |||||||||
| Address1: | 729 CORTARO DR | ||||||||
| Address2: | |||||||||
| City: | RUSKIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335736812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136330842 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AY871 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 4899832 | 01 | FL | GHI | OTHER | 600321400 | 05 | FL | MEDICAID |