1588788483 NPI number — MR. THADDEUS WICKI LMFT

Table of content: MR. THADDEUS WICKI LMFT (NPI 1588788483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588788483 NPI number — MR. THADDEUS WICKI LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKI
Provider First Name:
THADDEUS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588788483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12168 MOUNT VERNON AVE APT 58
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND TERRACE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92313-5543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-783-6796
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1688 N PERRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE L-10
Provider Business Practice Location Address City Name:
PERRIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92571-4709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-443-2200
Provider Business Practice Location Address Fax Number:
951-443-2230
Provider Enumeration Date:
03/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MFC 42602 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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