Provider Demographics
NPI:1801025911
Name:WICKES, KEVIN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:L
Last Name:WICKES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 RICHLAND MEDICAL PARK DR
Mailing Address - Street 2:SUITE 440
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6859
Mailing Address - Country:US
Mailing Address - Phone:803-434-2767
Mailing Address - Fax:803-434-2850
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 440
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-2767
Practice Address - Fax:803-434-2850
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3694101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional