Provider Demographics
NPI:1275007338
Name:WICKERSHAM, MICKY (CMHC)
Entity Type:Individual
Prefix:
First Name:MICKY
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:M
Other - Last Name:WICKERSHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMHC
Mailing Address - Street 1:7339 S HICKORY HILL CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4410
Mailing Address - Country:US
Mailing Address - Phone:801-554-0006
Mailing Address - Fax:
Practice Address - Street 1:8155 S BRIGHTON LOOP RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:UT
Practice Address - Zip Code:84121-9779
Practice Address - Country:US
Practice Address - Phone:801-593-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012474-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty