Provider Demographics
NPI:1174717094
Name:WICK, WENDY LYN (RN,LPC,SAC)
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:LYN
Last Name:WICK
Suffix:
Gender:F
Credentials:RN,LPC,SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13035 W BLUEMOUND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-8001
Mailing Address - Country:US
Mailing Address - Phone:262-408-1125
Mailing Address - Fax:
Practice Address - Street 1:13035 W BLUEMOUND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-8001
Practice Address - Country:US
Practice Address - Phone:262-408-1125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3937-125101YP2500X
WI15465-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1174717094Medicaid