Healthcare Provider Details

I. General information

NPI: 1457647307
Provider Name (Legal Business Name): MICHAEL JAMES WYLYKANOWITZ JR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MOUNTAIN BLVD BUILDING C
WARREN NJ
07059-2640
US

IV. Provider business mailing address

622 EAGLE ROCK AVE
WEST ORANGE NJ
07052-2994
US

V. Phone/Fax

Practice location:
  • Phone: 908-222-0515
  • Fax: 908-222-0516
Mailing address:
  • Phone: 973-669-0078
  • Fax: 973-669-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01398100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: