Provider Demographics
NPI:1366594202
Name:WICKSTROM, DAVID LEE (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:WICKSTROM
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:420 LONGTOWN RD W
Mailing Address - Street 2:
Mailing Address - City:BLYTHEWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29016-9450
Mailing Address - Country:US
Mailing Address - Phone:803-318-2009
Mailing Address - Fax:803-691-9298
Practice Address - Street 1:7520 MONTICELLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-1516
Practice Address - Country:US
Practice Address - Phone:803-254-3313
Practice Address - Fax:803-254-0370
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0591103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical