Provider Demographics
NPI:1225002108
Name:WISOCKI, TODD ANTHONY (ATC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ANTHONY
Last Name:WISOCKI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16901 COLONY LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9610
Mailing Address - Country:US
Mailing Address - Phone:239-466-5812
Mailing Address - Fax:
Practice Address - Street 1:11000 EVERBLADES PKWY
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9412
Practice Address - Country:US
Practice Address - Phone:239-948-7825
Practice Address - Fax:239-948-2248
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL13162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer