Healthcare Provider Details

I. General information

NPI: 1023527892
Provider Name (Legal Business Name): HOLLY LYNN WICKIZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 S. COLUMBIAN WAY
SEATTLE WA
98108
US

IV. Provider business mailing address

8805 2ND AVE S
SEATTLE WA
98108-4502
US

V. Phone/Fax

Practice location:
  • Phone: 206-321-1907
  • Fax:
Mailing address:
  • Phone: 206-321-1907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13304
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCG60771577
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: