Healthcare Provider Details

I. General information

NPI: 1508996331
Provider Name (Legal Business Name): GEOFFREY MARTIN WYCKOFF PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082 TAYLORSVILLE RD SUITE 105
WASHINGTON CROSSING PA
18977-1305
US

IV. Provider business mailing address

1082 TAYLORSVILLE RD SUITE 105
WASHINGTON CROSSING PA
18977-1305
US

V. Phone/Fax

Practice location:
  • Phone: 267-399-9962
  • Fax: 267-392-5236
Mailing address:
  • Phone: 267-399-9962
  • Fax: 267-392-5236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS007870L
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS007870L
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35510065400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: