Provider Demographics
NPI:1265488159
Name:WICK, JAMES H (EDD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:WICK
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-7180
Mailing Address - Fax:
Practice Address - Street 1:1621 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-328-4700
Practice Address - Fax:605-328-4702
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD184103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD680015124Medicare PIN
SDS40729Medicare PIN