Provider Demographics
NPI:1174068738
Name:WICKLUND, MEGAN LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LYNN
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 CRAYTON CIR W
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1770
Mailing Address - Country:US
Mailing Address - Phone:630-877-8004
Mailing Address - Fax:
Practice Address - Street 1:1440 RENAISSANCE DR STE 320
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1471
Practice Address - Country:US
Practice Address - Phone:224-325-5258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0185121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL474579189001Medicaid