Provider Demographics
NPI:1225712193
Name:WICKLINE, TRISHA NICOLE
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:NICOLE
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 E GRAFTON RD STE C
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4465
Mailing Address - Country:US
Mailing Address - Phone:304-366-5832
Mailing Address - Fax:
Practice Address - Street 1:14 E GRAFTON RD STE C
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4465
Practice Address - Country:US
Practice Address - Phone:304-366-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPL052417083104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker