Individual
MS. HOLLY D WICKENHAUSER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ATC
Contact information
Practice address
1111 TRINITY LN, SUITE 111, BLOOMINGTON, IL 61704-8111
(309) 663-6461
(309) 663-5711
Mailing address
1111 TRINITY LN, SUITE 111, BLOOMINGTON, IL 61704-8111
(309) 663-6461
(309) 663-5711
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
096.001891
IL
Other
Enumeration date
04/23/2008
Last updated
01/04/2017
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