Provider Demographics
NPI:1477869188
Name:WICKS, FRED G (PHD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:G
Last Name:WICKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1943 ARMSTRONG DR
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-5669
Mailing Address - Country:US
Mailing Address - Phone:215-699-2437
Mailing Address - Fax:215-699-7681
Practice Address - Street 1:1943 ARMSTRONG DR
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5669
Practice Address - Country:US
Practice Address - Phone:215-699-2437
Practice Address - Fax:215-699-7681
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 001732-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000029388OtherHIGHMARK BLUE SHIELD
PAPO 27868OtherADMINISTAR DEFENSE SERVICES