Provider Demographics
NPI:1285085316
Name:WICKER, KATIE (LISW-CP)
Entity type:Individual
Prefix:MS
First Name:KATIE
Middle Name:
Last Name:WICKER
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 LANDMARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4015
Mailing Address - Country:US
Mailing Address - Phone:803-470-3882
Mailing Address - Fax:
Practice Address - Street 1:3621 LANDMARK DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4015
Practice Address - Country:US
Practice Address - Phone:803-470-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical