Healthcare Provider Details

I. General information

NPI: 1033257647
Provider Name (Legal Business Name): PATRICIA M. WYCKOFF PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N MAIN ST
MANSFIELD MA
02048-3803
US

IV. Provider business mailing address

15 KING ARTHUR WAY
MANSFIELD MA
02048-1739
US

V. Phone/Fax

Practice location:
  • Phone: 508-337-6127
  • Fax: 508-337-6399
Mailing address:
  • Phone: 508-337-6127
  • Fax: 508-337-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4264
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: