Healthcare Provider Details

I. General information

NPI: 1194003459
Provider Name (Legal Business Name): TRACYLYNN HUNTLEY WICKHAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2011
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 GLENSIDE DR STE F
RICHMOND VA
23228-3995
US

IV. Provider business mailing address

1640 E PARHAM RD
RICHMOND VA
23228-2368
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-5880
  • Fax: 804-288-2029
Mailing address:
  • Phone: 804-272-2000
  • Fax: 804-272-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006713
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: