Provider Demographics
NPI:1336333285
Name:WICKS, BETTY (PSYD)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21031 MARKET RDG
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-2483
Mailing Address - Country:US
Mailing Address - Phone:210-233-6148
Mailing Address - Fax:210-399-8721
Practice Address - Street 1:4400 NW LOOP 410 STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5178
Practice Address - Country:US
Practice Address - Phone:210-516-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
TX38180103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health