Provider Demographics
NPI:1831620855
Name:WICKERSON, KACY
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:
Last Name:WICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KACY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11112 SCRIMSHAW LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8304
Mailing Address - Country:US
Mailing Address - Phone:704-258-7031
Mailing Address - Fax:
Practice Address - Street 1:11112 SCRIMSHAW LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-8304
Practice Address - Country:US
Practice Address - Phone:704-258-7031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011439235Z00000X
SC6006235Z00000X
NC12381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty