Provider Demographics
NPI:1386115707
Name:WICK, KEITH (LICSW)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:WICK
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ESSEX RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-1450
Mailing Address - Country:US
Mailing Address - Phone:617-696-2908
Mailing Address - Fax:
Practice Address - Street 1:275 COMMON ST
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081-3254
Practice Address - Country:US
Practice Address - Phone:508-660-7257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1118121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical