Provider Demographics
NPI:1710507793
Name:WICKHAM, KAELY NICOLE
Entity Type:Individual
Prefix:
First Name:KAELY
Middle Name:NICOLE
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5812
Mailing Address - Country:US
Mailing Address - Phone:425-922-5278
Mailing Address - Fax:
Practice Address - Street 1:1700 AIRPORT WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1618
Practice Address - Country:US
Practice Address - Phone:206-223-3644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor