Provider Demographics
NPI:1275893323
Name:NICKERSON, WENDY ELAINE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:ELAINE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9023 E. DESERT COVE CRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-5432
Mailing Address - Country:US
Mailing Address - Phone:480-614-2774
Mailing Address - Fax:
Practice Address - Street 1:9023 E. DESERT COVE CRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-5432
Practice Address - Country:US
Practice Address - Phone:480-614-2774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-23
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4277103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist