Provider Demographics
NPI:1053897363
Name:WICKE, KRISTEN K (MA, LPC)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:K
Last Name:WICKE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-4405
Mailing Address - Country:US
Mailing Address - Phone:512-560-8332
Mailing Address - Fax:
Practice Address - Street 1:3700 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7046
Practice Address - Country:US
Practice Address - Phone:512-735-2430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76237101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor