Provider Demographics
NPI:1609918663
Name:WICKHAM, THOMAS ALLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ALLEN
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:A
Other - Last Name:WICKHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1210 NEVADA ST
Mailing Address - Street 2:SUITE101
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2895
Mailing Address - Country:US
Mailing Address - Phone:909-793-8312
Mailing Address - Fax:909-792-6507
Practice Address - Street 1:1210 NEVADA ST
Practice Address - Street 2:SUITE101
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2895
Practice Address - Country:US
Practice Address - Phone:909-793-8312
Practice Address - Fax:909-792-6507
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6128103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TP0814X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy