Provider Demographics
NPI:1427211465
Name:WICKS, EVELYN TERRY (DUI)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:TERRY
Last Name:WICKS
Suffix:
Gender:F
Credentials:DUI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11960 HERITAGE OAK PL
Mailing Address - Street 2:STE 15
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2401
Mailing Address - Country:US
Mailing Address - Phone:530-885-1961
Mailing Address - Fax:530-885-0713
Practice Address - Street 1:11960 HERITAGE OAK PL
Practice Address - Street 2:STE 15
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2401
Practice Address - Country:US
Practice Address - Phone:530-885-1961
Practice Address - Fax:530-885-0713
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
W0408271744101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)