MEDICARE: SANDRA ANN WICKHAM LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R023765-1	NY
2	1041C0700X	Clinical Social Worker	C006197	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659381382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA ANN WICKHAM LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1668
Second Line	:
City	:	PITTSBORO
State	:	NC
Zip	:	27312-1668
Country	:	US
Telephone Number	:	919-542-4952
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 VILLAGE LAKE RD
Second Line	:	SILER BUSINESS PARK BLDG#1 SUITE B
City	:	SILER CITY
State	:	NC
Zip	:	27344-1821
Country	:	US
Telephone Number	:	919-542-4952
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	12/23/2011

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