MEDICARE: MS. DIANE MARIE WICK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501002417	MI

General Provider Information

NPI Number	:	1750341129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANE MARIE WICK PT

Provider Business Mailing Address
First Line	:	12400 ALCOY DR
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430
Country	:	US
Telephone Number	:	810-629-8321
Fax Number	:

Provider Business Practice Location Address
First Line	:	6012 S LINDEN RD
Second Line	:	STE 15
City	:	SWARTZ CREEK
State	:	MI
Zip	:	48473
Country	:	US
Telephone Number	:	810-655-8244
Fax Number	:	810-655-2192

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	07/08/2007

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