Provider Demographics
NPI:1932534633
Name:WICKLUND, KELLIE LYNN (MA, NCP, LPC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYNN
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:MA, NCP, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 OLD YORK RD
Mailing Address - Street 2:SUITE - 302
Mailing Address - City:ABINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19001-3413
Mailing Address - Country:US
Mailing Address - Phone:267-432-2374
Mailing Address - Fax:
Practice Address - Street 1:1355 OLD YORK RD
Practice Address - Street 2:SUITE - 302
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3413
Practice Address - Country:US
Practice Address - Phone:267-432-2374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC004810101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health