Provider Demographics
NPI:1952495053
Name:WIKSTROM, PAUL V (LICSW)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:V
Last Name:WIKSTROM
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MAPLE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-2741
Mailing Address - Country:US
Mailing Address - Phone:617-429-7483
Mailing Address - Fax:
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1148701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA114870OtherLICSW LICENSE