Healthcare Provider Details

I. General information

NPI: 1346793254
Provider Name (Legal Business Name): LENA-ANNE WICKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 TOZER RD
BEVERLY MA
01915-5515
US

IV. Provider business mailing address

16 BANKS ST
WINTHROP MA
02152-1904
US

V. Phone/Fax

Practice location:
  • Phone: 978-969-2894
  • Fax:
Mailing address:
  • Phone: 617-207-9211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1966
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: