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General NPI Number Information
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NPI Number | 1912180027
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Entity Type | Organization
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Legal Business Name | MATTHEW WADE WICHT
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Dates
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Enumeration Date | 12/12/2007
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Last Update Date | 07/30/2008
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Provider Practice Location Address
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Address Line | 2222 N US HIGHWAY 67
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City | FLORISSANT
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State | MO
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Zip | 63033-2032
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Country | US
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Telephone | 314-831-2225
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Fax |
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Provider Business Mailing Address
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Address Line | 700 GINGER WOOD CT
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City | BALLWIN
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State | MO
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Zip | 63021-8438
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Country | US
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Telephone | 636-225-8877
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MATTHEW WADE WICHT
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Credential | LPC, NCC, CEAP
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Telephone | 636-225-8877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 2001014011
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 1035
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1035
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License Number State | MS
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 2001014011
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License Number State | MO
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