Healthcare Provider Details

I. General information

NPI: 1770845687
Provider Name (Legal Business Name): AMY WICHMAN L.P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 BRAEBURN RD
CHARLOTTE NC
28211-4768
US

IV. Provider business mailing address

1209 BRAEBURN RD
CHARLOTTE NC
28211-4768
US

V. Phone/Fax

Practice location:
  • Phone: 704-293-7231
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2352
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: