Provider Demographics
NPI:1689071862
Name:WICKS, KELLY (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-1430
Mailing Address - Country:US
Mailing Address - Phone:612-871-1454
Mailing Address - Fax:612-871-1505
Practice Address - Street 1:1100 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1430
Practice Address - Country:US
Practice Address - Phone:612-871-1454
Practice Address - Fax:612-871-1505
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5806103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical