Provider Demographics
NPI:1710070040
Name:WICKLEIN, BETSY LEE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:BETSY
Middle Name:LEE
Last Name:WICKLEIN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 VILLAGE DR
Mailing Address - Street 2:P.O. BOX 626
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6004
Mailing Address - Country:US
Mailing Address - Phone:706-769-1718
Mailing Address - Fax:706-769-4535
Practice Address - Street 1:1030 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6004
Practice Address - Country:US
Practice Address - Phone:706-769-1718
Practice Address - Fax:706-769-4535
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional