Healthcare Provider Details

I. General information

NPI: 1578524229
Provider Name (Legal Business Name): MARC WYSOCKI ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N UNDERMOUNTAIN RD
SHEFFIELD MA
01257-9638
US

IV. Provider business mailing address

245 N UNDERMOUNTAIN RD
SHEFFIELD MA
01257-9638
US

V. Phone/Fax

Practice location:
  • Phone: 413-229-1296
  • Fax: 413-229-1109
Mailing address:
  • Phone: 413-229-1296
  • Fax: 413-229-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number914
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: