Provider Demographics
NPI:1861697542
Name:WICKMAN, SALLY ANN (COTA)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3725
Mailing Address - Country:US
Mailing Address - Phone:941-488-7313
Mailing Address - Fax:
Practice Address - Street 1:3417 TAMIAMI TRL STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8158
Practice Address - Country:US
Practice Address - Phone:941-624-6222
Practice Address - Fax:941-624-6821
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT6185224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant