Provider Demographics
NPI:1942730155
Name:WICKHAM, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5102 WRIGHTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-7054
Mailing Address - Country:US
Mailing Address - Phone:910-612-8123
Mailing Address - Fax:
Practice Address - Street 1:5102 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7054
Practice Address - Country:US
Practice Address - Phone:910-612-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-23702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)