Healthcare Provider Details

I. General information

NPI: 1912724741
Provider Name (Legal Business Name): SARAH MARIE WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14176 NATIONAL RD SW
ETNA OH
43068-3363
US

IV. Provider business mailing address

14176 NATIONAL RD SW
ETNA OH
43068-3363
US

V. Phone/Fax

Practice location:
  • Phone: 740-927-6782
  • Fax: 740-927-9018
Mailing address:
  • Phone: 740-927-6782
  • Fax: 740-927-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2326
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: