Healthcare Provider Details

I. General information

NPI: 1629442793
Provider Name (Legal Business Name): WYCKOFF PHYSICAL THERAPY PC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2015
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6805 FRESH POND RD
RIDGEWOOD NY
11385-5200
US

IV. Provider business mailing address

201 SAINT NICHOLAS AVE
BROOKLYN NY
11237-4840
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-2543
  • Fax: 718-559-6784
Mailing address:
  • Phone: 718-821-9511
  • Fax: 718-559-6784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNY TAN
Title or Position: BILLING & COLLECTION DEPT. HEAD
Credential:
Phone: 718-456-2543