Provider Demographics
NPI:1336464817
Name:WICKER, LAURA L
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WICKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 SGT JOHN A PITTMAN DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-7343
Mailing Address - Country:US
Mailing Address - Phone:662-453-9173
Mailing Address - Fax:662-455-4933
Practice Address - Street 1:902 SGT JOHN A PITTMAN DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-7343
Practice Address - Country:US
Practice Address - Phone:662-453-9173
Practice Address - Fax:662-455-4933
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist