Provider Demographics
NPI:1588788483
Name:WICKI, THADDEUS (LMFT)
Entity type:Individual
Prefix:MR
First Name:THADDEUS
Middle Name:
Last Name:WICKI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12168 MOUNT VERNON AVE APT 58
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5543
Mailing Address - Country:US
Mailing Address - Phone:909-783-6796
Mailing Address - Fax:
Practice Address - Street 1:1688 N PERRIS BLVD
Practice Address - Street 2:SUITE L-10
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-4709
Practice Address - Country:US
Practice Address - Phone:951-443-2200
Practice Address - Fax:951-443-2230
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 42602101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health