Provider Demographics
NPI:1285114876
Name:WYCKOFF, CONNOR BLAKE (LSCSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:BLAKE
Last Name:WYCKOFF
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SW JACKSON ST
Mailing Address - Street 2:STE 618 #528
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66612
Mailing Address - Country:US
Mailing Address - Phone:785-414-9911
Mailing Address - Fax:785-414-5228
Practice Address - Street 1:800 SW JACKSON ST
Practice Address - Street 2:STE 618 #528
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66612
Practice Address - Country:US
Practice Address - Phone:785-414-9911
Practice Address - Fax:785-414-5228
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS053421041C0700X
KS10930104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker