Provider Demographics
NPI:1700515020
Name:WICKLIFFE, ELIZABETH (BS)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 S 600 E
Mailing Address - Street 2:
Mailing Address - City:AVILLA
Mailing Address - State:IN
Mailing Address - Zip Code:46710-9620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6130 COUNTY ROAD 427
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-9515
Practice Address - Country:US
Practice Address - Phone:260-920-0784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker