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General NPI Number Information
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NPI Number | 1912215369
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Entity Type | Individual
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Provider Name | SUSAN L WICKETT LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/20/2010
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Last Update Date | 04/11/2019
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Provider Practice Location Address
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Address Line | 313 ROBIN LN
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City | SALLISAW
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State | OK
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Zip | 74955-3028
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Country | US
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Telephone | 609-346-8746
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Fax |
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Provider Business Mailing Address
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Address Line | 313 ROBIN LN
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City | SALLISAW
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State | OK
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Zip | 74955-3028
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Country | US
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Telephone | 609-346-8746
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C006886
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 9610
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 58992
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License Number State | TX
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