Basic Information
| Provider Information | |||||||||
| NPI: | 1285114876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYCKOFF | ||||||||
| FirstName: | CONNOR | ||||||||
| MiddleName: | BLAKE | ||||||||
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| Credential: | LSCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | 7858432219 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | 7858432219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2018 | ||||||||
| LastUpdateDate: | 01/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 10930 | KS | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 05342 | KS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.