MEDICARE: SHARON J WICKHAM LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	0904002779	VA

General Provider Information

NPI Number	:	1194800771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON J WICKHAM LCSW

Provider Business Mailing Address
First Line	:	921 FIRST COLONIAL RD STE 1711
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-3167
Country	:	US
Telephone Number	:	757-428-7500
Fax Number	:	757-428-7699

Provider Business Practice Location Address
First Line	:	921 FIRST COLONIAL RD STE 1711
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-3167
Country	:	US
Telephone Number	:	757-428-7500
Fax Number	:	757-428-7699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	12/19/2007

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