MEDICARE: SHAUNA ANN WICKHAM LPC

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	101YP2500X	Professional Counselor	20214	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20214	OTHER	TX	LPC LICENSE

General Provider Information

NPI Number	:	1972675957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNA ANN WICKHAM LPC

Provider Business Mailing Address
First Line	:	321 RED OAK LN
Second Line	:
City	:	INGRAM
State	:	TX
Zip	:	78025-3616
Country	:	US
Telephone Number	:	830-370-2562
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 RED OAK LN
Second Line	:
City	:	INGRAM
State	:	TX
Zip	:	78025-3616
Country	:	US
Telephone Number	:	830-370-2562
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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