Provider Demographics
NPI:1730710815
Name:WICKS, BRIAN ALLEN (MFT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ALLEN
Last Name:WICKS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8421 WAYZATA BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1382
Mailing Address - Country:US
Mailing Address - Phone:952-835-6540
Mailing Address - Fax:651-925-0089
Practice Address - Street 1:8421 WAYZATA BLVD STE 250
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1382
Practice Address - Country:US
Practice Address - Phone:952-835-6540
Practice Address - Fax:651-925-0089
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3970101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health