Provider Demographics
NPI:1275007338
Name:WICKERSHAM, MICHELLE M (CMHC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:MICKY
Other - Middle Name:M
Other - Last Name:WICKERSHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMHC
Mailing Address - Street 1:1084 WEAVER LN
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3514
Mailing Address - Country:US
Mailing Address - Phone:801-899-9492
Mailing Address - Fax:801-899-7793
Practice Address - Street 1:4455 S 700 E STE 300
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-3076
Practice Address - Country:US
Practice Address - Phone:801-899-9492
Practice Address - Fax:801-899-7793
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9012474-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty