Provider Demographics
NPI:1356833164
Name:WYCKOFF, JOEL (PTA)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:WYCKOFF
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 S GREEN BAY RD STE 205
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4469
Mailing Address - Country:US
Mailing Address - Phone:262-898-3930
Mailing Address - Fax:414-438-3176
Practice Address - Street 1:9120 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1622
Practice Address - Country:US
Practice Address - Phone:414-438-3177
Practice Address - Fax:414-438-3176
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2006-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant