Provider Demographics
NPI:1780215830
Name:WICKS, KATY
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:WICKS
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 1:2722 COLBY AVE STE 610
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3534
Mailing Address - Country:US
Mailing Address - Phone:425-328-5193
Mailing Address - Fax:
Practice Address - Street 1:2722 COLBY AVE STE 610
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3534
Practice Address - Country:US
Practice Address - Phone:425-328-5193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61039175101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor