Provider Demographics
NPI:1427541358
Name:WICKS, ANDREA REBECCA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:REBECCA
Last Name:WICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 W LA VETA AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4448
Mailing Address - Country:US
Mailing Address - Phone:714-532-9295
Mailing Address - Fax:
Practice Address - Street 1:705 W LA VETA AVE STE 208
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4448
Practice Address - Country:US
Practice Address - Phone:714-532-9295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)