Provider Demographics
NPI:1457647307
Name:WYLYKANOWITZ, MICHAEL JAMES JR (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:WYLYKANOWITZ
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2994
Mailing Address - Country:US
Mailing Address - Phone:973-669-0078
Mailing Address - Fax:973-669-1113
Practice Address - Street 1:34 MOUNTAIN BLVD
Practice Address - Street 2:BUILDING C
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-2640
Practice Address - Country:US
Practice Address - Phone:908-222-0515
Practice Address - Fax:908-222-0516
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01398100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist