Healthcare Provider Details

I. General information

NPI: 1760039531
Provider Name (Legal Business Name): EMILY WICKER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

PO BOX 25704
ALBUQUERQUE NM
87125-0704
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: