Provider Demographics
NPI:1679574297
Name:WICKWARE, SUSAN S (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:S
Last Name:WICKWARE
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 1:12 WEXFORD CT
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1802
Mailing Address - Country:US
Mailing Address - Phone:856-489-1182
Mailing Address - Fax:856-256-8390
Practice Address - Street 1:901 ROUTE 38
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2857
Practice Address - Country:US
Practice Address - Phone:856-489-1182
Practice Address - Fax:856-256-8390
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-06-26
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00489700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ063438Medicare ID - Type Unspecified