Healthcare Provider Details

I. General information

NPI: 1366423006
Provider Name (Legal Business Name): ALYSE SICKLICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GAYLORD FARMS RD
WALLINGFORD CT
06492
US

IV. Provider business mailing address

PO BOX 400 GAYLORD FARMS RD
WALLINGFORD CT
06492-7048
US

V. Phone/Fax

Practice location:
  • Phone: 203-284-2800
  • Fax: 203-679-3598
Mailing address:
  • Phone: 203-284-2800
  • Fax: 203-679-3598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number032242
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: