Basic Information
| Provider Information | |||||||||
| NPI: | 1861558884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5934 S BUSINESS DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530818914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204599277 | ||||||||
| FaxNumber: | 9204597920 | ||||||||
| Practice Location | |||||||||
| Address1: | 5934 S BUSINESS DR | ||||||||
| Address2: | |||||||||
| City: | SHEBOYGAN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530818914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204599277 | ||||||||
| FaxNumber: | 9204597920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2430123 | WI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 177124 | WI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YA0400X | 12399131 | WI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 2430-123 | WI | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.