Provider Demographics
NPI:1487705828
Name:WICK, PATRICIA L (PHD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:L
Last Name:WICK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 RESERVOIR CIR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6324
Mailing Address - Country:US
Mailing Address - Phone:410-664-0688
Mailing Address - Fax:410-664-0683
Practice Address - Street 1:8 RESERVOIR CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6324
Practice Address - Country:US
Practice Address - Phone:410-664-0688
Practice Address - Fax:410-664-0683
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02763103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR6690001OtherBCBS
MD004898OtherVALUEOPTIONS
MDGJ58Medicare ID - Type Unspecified
MDGJ58Medicare ID - Type Unspecified