Provider Demographics
NPI:1679778369
Name:WIKLACZ, MARY (LISW-CP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WIKLACZ
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CROWN EMPIRE CT
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6354
Mailing Address - Country:US
Mailing Address - Phone:864-289-0043
Mailing Address - Fax:
Practice Address - Street 1:7 PETTIGRU ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3000
Practice Address - Country:US
Practice Address - Phone:864-235-7501
Practice Address - Fax:864-235-7503
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical