Provider Demographics
NPI:1275959876
Name:WICKERHAM, BLAKE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:WICKERHAM
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 WOODS PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-5231
Mailing Address - Country:US
Mailing Address - Phone:919-515-2111
Mailing Address - Fax:
Practice Address - Street 1:3121 WOODS PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-5231
Practice Address - Country:US
Practice Address - Phone:919-515-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer