Provider Demographics
NPI:1548476104
Name:WICKHAM, KELLY LEE
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEE
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 GLENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-1575
Mailing Address - Country:US
Mailing Address - Phone:818-242-9357
Mailing Address - Fax:
Practice Address - Street 1:1147 S ALVARADO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-4100
Practice Address - Country:US
Practice Address - Phone:213-381-8526
Practice Address - Fax:213-381-8533
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)