Provider Demographics
NPI:1104426204
Name:WICKERSHAM, AIMEE BENTON (LCSW)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:BENTON
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15593 W MACKENZIE DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-7779
Mailing Address - Country:US
Mailing Address - Phone:321-961-3393
Mailing Address - Fax:
Practice Address - Street 1:15593 W MACKENZIE DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-7779
Practice Address - Country:US
Practice Address - Phone:321-961-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-189141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical