Provider Demographics
NPI:1245558154
Name:WICKER, BEVERLY A (LCSW, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:WICKER
Suffix:
Gender:F
Credentials:LCSW, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4206
Mailing Address - Country:US
Mailing Address - Phone:919-774-1131
Mailing Address - Fax:877-600-5440
Practice Address - Street 1:201 SHANNON OAKS CIR STE 200
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-415-4244
Practice Address - Fax:877-600-5440
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-17
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-2039101YA0400X
NCC0067961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007548Medicaid
NC6007548Medicaid