MEDICARE: MRS. WENDY WIKSTROM LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-24147	AZ
2	101YM0800X	Mental Health Counselor	7386	ID

General Provider Information

NPI Number	:	1962173302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WENDY WIKSTROM LPC

Provider Business Mailing Address
First Line	:	1950 E CLEAR LAKE DR
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6742
Country	:	US
Telephone Number	:	928-538-2011
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 E CLEAR LAKE DR
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6742
Country	:	US
Telephone Number	:	928-538-2011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2021
Last Update Date	:	12/18/2025

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