Provider Demographics
NPI:1275007338
Name:WICKERSHAM, MICHELLE M (CMHC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:MICKY
Other - Middle Name:M
Other - Last Name:WICKERSHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMHC
Mailing Address - Street 1:1084 WEAVER LN
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3514
Mailing Address - Country:US
Mailing Address - Phone:801-554-0006
Mailing Address - Fax:801-899-7793
Practice Address - Street 1:476 HERITAGE PARK BLVD STE 220
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5679
Practice Address - Country:US
Practice Address - Phone:801-554-0006
Practice Address - Fax:801-899-7793
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012474-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty