Healthcare Provider Details

I. General information

NPI: 1366594202
Provider Name (Legal Business Name): DAVID LEE WICKSTROM PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTICELLO RD
COLUMBIA SC
29203-1516
US

IV. Provider business mailing address

420 LONGTOWN RD W
BLYTHEWOOD SC
29016-9450
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-3313
  • Fax: 803-254-0370
Mailing address:
  • Phone: 803-318-2009
  • Fax: 803-691-9298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0591
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: