Healthcare Provider Details

I. General information

NPI: 1508064627
Provider Name (Legal Business Name): WYCKOFF PHYSICAL THERAPY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 WYCKOFF AVE A1A
MAHWAH NJ
07430-3186
US

IV. Provider business mailing address

860 WYCKOFF AVE A1A
MAHWAH NJ
07430-3186
US

V. Phone/Fax

Practice location:
  • Phone: 201-891-9008
  • Fax: 201-891-9195
Mailing address:
  • Phone: 201-891-9008
  • Fax: 201-891-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number40QA00499000
License Number StateNJ

VIII. Authorized Official

Name: STEPHEN NEWMAN
Title or Position: PRESIDENT
Credential: LPT
Phone: 201-891-9008