Provider Demographics
NPI:1770017139
Name:WICOFF, MARIBETH
Entity Type:Individual
Prefix:
First Name:MARIBETH
Middle Name:
Last Name:WICOFF
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 1:2500 METROHEALTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-1998
Mailing Address - Country:US
Mailing Address - Phone:216-778-4486
Mailing Address - Fax:
Practice Address - Street 1:2500 METROHEALTH DRIVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1998
Practice Address - Country:US
Practice Address - Phone:216-778-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018821103TC2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent