=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770625212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDLANDS PSYCHOLOGICAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 NEVADA ST SUITE101
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-2895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-793-8312
-----------------------------------------------------
Fax | 909-792-6507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 NEVADA ST SUITE101
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-2895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-793-8312
-----------------------------------------------------
Fax | 909-792-6507
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS ALLEN WICKHAM
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 909-793-8312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------