Provider Demographics
NPI:1427536812
Name:WICKER, ISAAC (BS)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:WICKER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 768
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-0768
Mailing Address - Country:US
Mailing Address - Phone:815-844-6109
Mailing Address - Fax:815-844-3561
Practice Address - Street 1:310 E TORRANCE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health