Provider Demographics
NPI:1659381382
Name:WICKHAM, SANDRA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ANN
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:LCSW
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 1668
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-1668
Mailing Address - Country:US
Mailing Address - Phone:919-542-4952
Mailing Address - Fax:
Practice Address - Street 1:110 VILLAGE LAKE RD
Practice Address - Street 2:SILER BUSINESS PARK BLDG#1 SUITE B
Practice Address - City:SILER CITY
Practice Address - State:NC
Practice Address - Zip Code:27344-1821
Practice Address - Country:US
Practice Address - Phone:919-542-4952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR023765-11041C0700X
NCC0061971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13389Medicaid