Provider Demographics
NPI:1114465739
Name:WICK, ELIZABETH (PTA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WICK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 MONTGOMERY ST
Mailing Address - Street 2:STE 4
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3869
Mailing Address - Country:US
Mailing Address - Phone:201-721-6130
Mailing Address - Fax:201-918-6864
Practice Address - Street 1:31 MONTGOMERY ST
Practice Address - Street 2:STE 4
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-3869
Practice Address - Country:US
Practice Address - Phone:201-721-6130
Practice Address - Fax:201-918-6864
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00336900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant