Provider Demographics
NPI:1821031956
Name:WICKLUND, ALISSA HAYS (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALISSA
Middle Name:HAYS
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:970-419-7160
Practice Address - Street 1:2500 E PROSPECT RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9718
Practice Address - Country:US
Practice Address - Phone:773-818-0669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY.0004045103G00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1821031956OtherGROUP MEMBER NATHIONAL PROVIDER IDENTIFIER