Healthcare Provider Details

I. General information

NPI: 1871607788
Provider Name (Legal Business Name): BERNADETTE MARIE WYCKOFF PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 GEORGIA AVE NW
WASHINGTON DC
20307-0003
US

IV. Provider business mailing address

17821 TREE LAWN DR
ASHTON MD
20861-3344
US

V. Phone/Fax

Practice location:
  • Phone: 202-782-6371
  • Fax:
Mailing address:
  • Phone: 301-570-9068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14708
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: