Provider Demographics
NPI:1750001087
Name:WICKETT, CASSANDRA MAE
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MAE
Last Name:WICKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1791
Mailing Address - Street 2:15 SAGE HILL ROAD
Mailing Address - City:GLENROCK
Mailing Address - State:WY
Mailing Address - Zip Code:82637-1791
Mailing Address - Country:US
Mailing Address - Phone:307-262-8389
Mailing Address - Fax:
Practice Address - Street 1:145 W 9TH STREET
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-215-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY101Y00000X
WYPPC-1391101YP2500X
390200000X
WYLPC-2402101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program