Provider Demographics
NPI:1013700434
Name:WICKHAM, ELI
Entity type:Individual
Prefix:
First Name:ELI
Middle Name:
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BANKS ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152-1904
Mailing Address - Country:US
Mailing Address - Phone:857-272-7619
Mailing Address - Fax:
Practice Address - Street 1:16 BANKS ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1904
Practice Address - Country:US
Practice Address - Phone:857-272-7619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician