Provider Demographics
NPI:1013632330
Name:WICKSELL, CARLY ANN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:WICKSELL
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 1:2255 SW 37TH WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-4484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2255 SW 37TH WAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4484
Practice Address - Country:US
Practice Address - Phone:386-882-2053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVFM244898OtherFLORIDA HEALTH CARE PLANS