Provider Demographics
NPI:1396013306
Name:WICHMANN, CHRISTINE GOODRICH (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GOODRICH
Last Name:WICHMANN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2292 COUNTY ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:EAST CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12060-3709
Mailing Address - Country:US
Mailing Address - Phone:518-392-5333
Mailing Address - Fax:
Practice Address - Street 1:10 EMPIRE STATE BLVD
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9751
Practice Address - Country:US
Practice Address - Phone:518-477-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003327-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist