MEDICARE: KATHY WICKERSHAM

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	101YM0800X	Mental Health Counselor	10570331-6004	UT
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1912156431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY WICKERSHAM

Provider Business Mailing Address
First Line	:	1877 S WYOMING ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3235
Country	:	US
Telephone Number	:	801-712-1441
Fax Number	:

Provider Business Practice Location Address
First Line	:	1398 E LUCK LN
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2944
Country	:	US
Telephone Number	:	801-251-6767
Fax Number	:

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

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/20/2022

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Directions to “ KATHY WICKERSHAM ” Practice Location

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