Healthcare Provider Details

I. General information

NPI: 1972500544
Provider Name (Legal Business Name): CARL J. WIGHARDT M.S.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 S MAIN ST
HAVERHILL MA
01835-8721
US

IV. Provider business mailing address

790 DALE ST
NORTH ANDOVER MA
01845-1420
US

V. Phone/Fax

Practice location:
  • Phone: 978-372-3211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16417
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA08473
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: