Provider Demographics
NPI:1689339905
Name:WICKIZER, MICHELLE (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WICKIZER
Suffix:
Gender:F
Credentials:PSYD
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 38553
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80937-8553
Mailing Address - Country:US
Mailing Address - Phone:719-313-2578
Mailing Address - Fax:719-434-9811
Practice Address - Street 1:1229 LAKE PLAZA DR STE A
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-7401
Practice Address - Country:US
Practice Address - Phone:719-313-2578
Practice Address - Fax:719-735-4952
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0005676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical