Provider Demographics
NPI:1699832121
Name:WICKHAM, THOMAS W (LPC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:INGRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78025-3616
Mailing Address - Country:US
Mailing Address - Phone:830-377-8114
Mailing Address - Fax:
Practice Address - Street 1:321 RED OAK LN
Practice Address - Street 2:
Practice Address - City:INGRAM
Practice Address - State:TX
Practice Address - Zip Code:78025-3616
Practice Address - Country:US
Practice Address - Phone:830-377-8114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18372101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional