=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295931103
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WICK JOSEPH HAUPRICH PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1502 W WEST COVINA PKWY
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-2703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-480-5234
-----------------------------------------------------
Fax | 626-480-5109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 12509
-----------------------------------------------------
City | LA CRESCENTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91224-5509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-957-4239
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0004X
-----------------------------------------------------
Taxonomy Name | Health Psychologist
-----------------------------------------------------
License Number | PSY16665
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------