Provider Demographics
NPI:1497153977
Name:WICKERSHAM, PAUL (MS, LPC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:M
Credentials:MS, LPC
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 496
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-0496
Mailing Address - Country:US
Mailing Address - Phone:417-234-4423
Mailing Address - Fax:
Practice Address - Street 1:1675 E SEMINOLE ST
Practice Address - Street 2:SUITE H-2
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2490
Practice Address - Country:US
Practice Address - Phone:417-812-5263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002020617101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional