Provider Demographics
NPI:1750774741
Name:WICKHAM, MICHAEL JASON (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 GLENMERE AVE
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-1210
Mailing Address - Country:US
Mailing Address - Phone:845-741-9399
Mailing Address - Fax:
Practice Address - Street 1:118 GLENMERE AVE
Practice Address - Street 2:
Practice Address - City:FLORIDA
Practice Address - State:NY
Practice Address - Zip Code:10921-1210
Practice Address - Country:US
Practice Address - Phone:845-741-9399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2578981041C0700X
NJ44SC059237001041C0700X
NY095201-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical