Healthcare Provider Details

I. General information

NPI: 1457686073
Provider Name (Legal Business Name): RAINA WICKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 MAIN STREET, SUITE 105
PHILOMATH OR
97370
US

IV. Provider business mailing address

24971 BLUEROCK LN
CORVALLIS OR
97333-9554
US

V. Phone/Fax

Practice location:
  • Phone: 541-609-1305
  • Fax: 541-714-3770
Mailing address:
  • Phone: 541-609-1305
  • Fax: 541-714-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-12-75
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMASTERS - PSU
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500658765
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: