| Doctor Name: | MR. CARY VONN WICKERSHAM |
| NPI Number: | 1760796254 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 1105 Nw 5th St Stigler, OK - 744621615 |
| Business Phone Number: | 9184411669 |
| Business Fax Number: | 9189678617 |
| Mailing Address: | 1105 Nw 5th St, STIGLER |
| State: | OK |
| Postal Code: | 744621615 |
| Phone Number: | 9184411669 |
| Fax Number: | 9189678617 |
| NPI Enumeration Date: | 07/27/2010 |
| NPI Last Update Date: | 07/27/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |