Provider Demographics
NPI:1710595251
Name:WICKERSHAM, ROBERT (MA, RP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:M
Credentials:MA, RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 MCCASLIN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-2932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:357 MCCASLIN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2932
Practice Address - Country:US
Practice Address - Phone:303-946-4914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0017507101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional