1477107001 NPI number — RACHEL NADINE VAN WICKLE MS TLMFT

Table of content: RACHEL NADINE VAN WICKLE MS TLMFT (NPI 1477107001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477107001 NPI number — RACHEL NADINE VAN WICKLE MS TLMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN WICKLE
Provider First Name:
RACHEL
Provider Middle Name:
NADINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS TLMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477107001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 S PARK RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH LIBERTY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52317-9806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-448-7807
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1754 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241-1819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
194-931-9351
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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