Provider Demographics
NPI:1225533029
Name:WICKSTROM, BRENT
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WICKSTROM
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 1:3131 RDU CENTER DR STE 135
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-7687
Mailing Address - Country:US
Mailing Address - Phone:984-849-4447
Mailing Address - Fax:
Practice Address - Street 1:3131 RDU CENTER DR STE 135
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27560-7687
Practice Address - Country:US
Practice Address - Phone:984-849-4447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1-24-76014103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst