Healthcare Provider Details

I. General information

NPI: 1356833164
Provider Name (Legal Business Name): JOEL WYCKOFF PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W CAPITOL DR
MILWAUKEE WI
53222-1622
US

IV. Provider business mailing address

1300 S GREEN BAY RD STE 205
MOUNT PLEASANT WI
53406-4469
US

V. Phone/Fax

Practice location:
  • Phone: 414-438-3177
  • Fax: 414-438-3176
Mailing address:
  • Phone: 262-898-3930
  • Fax: 414-438-3176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2006-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: