Provider Demographics
NPI:1740321629
Name:WICKIZER, JOHN WILLIAM (LPC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:WICKIZER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CARDINAL PARK DR
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175
Mailing Address - Country:US
Mailing Address - Phone:703-715-6171
Mailing Address - Fax:
Practice Address - Street 1:2 CARDINAL PARK DR
Practice Address - Street 2:104A
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175
Practice Address - Country:US
Practice Address - Phone:703-715-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101YP2500X, 103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist