Provider Demographics
NPI:1750048500
Name:WICKLUND, CLARISSA (LMFT)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 GRANTSVILLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5761
Mailing Address - Country:US
Mailing Address - Phone:251-533-5520
Mailing Address - Fax:
Practice Address - Street 1:3720 GRANTSVILLE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5761
Practice Address - Country:US
Practice Address - Phone:251-533-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203398101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health