Healthcare Provider Details

I. General information

NPI: 1760489413
Provider Name (Legal Business Name): STEPHEN GERALD WYCHOCK P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 05/02/2006

III. Provider practice location address

607 LAKE AVE
ASHTABULA OH
44004-3262
US

IV. Provider business mailing address

607 LAKE AVE
ASHTABULA OH
44004-3262
US

V. Phone/Fax

Practice location:
  • Phone: 440-964-2035
  • Fax: 440-964-0699
Mailing address:
  • Phone: 440-964-2035
  • Fax: 440-964-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-6573
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License NumberPT-6573
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT-6573
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License NumberPT-6573
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPT-6573
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-6573
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT-6573
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-6573
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: