Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC1900X | Counseling Psychologist | 1256 | OK |
NPI | 1013378512 |
---|---|
Provider Name | Dr. Justin Wyckoff |
First Address | Norman, OK 73019-3142 |
Second Address | Norman, OK 73019-3142 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2016 |
Last Update Date | 10/03/2016 |