Provider Demographics
NPI:1992376099
Name:WICKETT, ERICA (LCAT, ATR-BC)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:WICKETT
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 6TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3639
Mailing Address - Country:US
Mailing Address - Phone:214-707-4547
Mailing Address - Fax:
Practice Address - Street 1:462 6TH ST APT 3B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3639
Practice Address - Country:US
Practice Address - Phone:214-707-4547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002430221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23334685OtherDRIVERS LICENSE