Provider Demographics
NPI:1265848246
Name:WICH, KATHRYN (MED/EDS, LMHC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WICH
Suffix:
Gender:F
Credentials:MED/EDS, LMHC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED/EDS, LMHC
Mailing Address - Street 1:1111 SE FEDERAL HWY STE 230
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3834
Mailing Address - Country:US
Mailing Address - Phone:772-221-4088
Mailing Address - Fax:
Practice Address - Street 1:1111 SE FEDERAL HWY STE 230
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3834
Practice Address - Country:US
Practice Address - Phone:772-221-4088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14365101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health