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General NPI Number Information
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NPI Number | 1801040878
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Entity Type | Individual
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Provider Name | MR. MATTHEW DAVID WICKSTROM
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Gender | Male
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Dates
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Enumeration Date | 11/04/2008
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Last Update Date | 11/04/2008
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Provider Practice Location Address
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Address Line | 27880 N 64TH STREET
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City | SCOTTSDALE
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State | AZ
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Zip | 85262
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Country | US
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Telephone | 480-202-8454
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Fax |
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Provider Business Mailing Address
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Address Line | 29862 N TATUM BLVD 2069
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City | CAVE CREEK
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State | AZ
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Zip | 85331-5860
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 4058847
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License Number State | AZ
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