Provider Demographics
NPI:1770511149
Name:WICKETT, AMANDA M (PSYD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:M
Last Name:WICKETT
Suffix:
Gender:F
Credentials:PSYD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1576
Mailing Address - Country:US
Mailing Address - Phone:574-732-1414
Mailing Address - Fax:574-732-0504
Practice Address - Street 1:1807 SMITH ST
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1576
Practice Address - Country:US
Practice Address - Phone:574-732-1414
Practice Address - Fax:574-732-0504
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042052A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20042052AOtherHSPP LICENSE