Provider Demographics
NPI:1932572161
Name:WICKERSHAM, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 S 700 E STE 17
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2583
Mailing Address - Country:US
Mailing Address - Phone:801-639-9544
Mailing Address - Fax:801-263-4333
Practice Address - Street 1:3970 S 700 E STE 17
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2583
Practice Address - Country:US
Practice Address - Phone:801-639-9544
Practice Address - Fax:801-263-4333
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9428093-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical