Provider Demographics
NPI:1902932551
Name:WICK, DANIEL T (PSYD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:WICK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:TIMPSON
Mailing Address - State:TX
Mailing Address - Zip Code:75975-0051
Mailing Address - Country:US
Mailing Address - Phone:936-668-1066
Mailing Address - Fax:936-647-1789
Practice Address - Street 1:689 COUNTY ROAD 4855
Practice Address - Street 2:
Practice Address - City:TIMPSON
Practice Address - State:TX
Practice Address - Zip Code:75975-5327
Practice Address - Country:US
Practice Address - Phone:936-668-1066
Practice Address - Fax:936-647-1789
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15745103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177329301Medicaid