Provider Demographics
NPI:1629643259
Name:WYCKOFF, KATHERINE LAURA (BS PSYCHOLOGY)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:LAURA
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:BS PSYCHOLOGY
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3015 GREYFIELD TRCE SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3015 GREYFIELD TRCE SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5531
Practice Address - Country:US
Practice Address - Phone:203-231-7859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARBT-21-168381106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician