Provider Demographics
NPI:1023223880
Name:WICKHAM, DAVID ELVIN (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ELVIN
Last Name:WICKHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16330 TR 289
Mailing Address - Street 2:
Mailing Address - City:CONESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43811
Mailing Address - Country:US
Mailing Address - Phone:740-623-4069
Mailing Address - Fax:740-623-4064
Practice Address - Street 1:353 WALNUT ST
Practice Address - Street 2:THREE RIVERS THERAPY SERVICES
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1531
Practice Address - Country:US
Practice Address - Phone:740-295-7080
Practice Address - Fax:740-295-7081
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5994225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist