Provider Demographics
NPI:1376757211
Name:WICKS, ROBERT J (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:WICKS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13275 HUNT RDG
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-1154
Mailing Address - Country:US
Mailing Address - Phone:410-531-6523
Mailing Address - Fax:
Practice Address - Street 1:13275 HUNT RDG
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-1154
Practice Address - Country:US
Practice Address - Phone:410-531-6523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMD2296103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical