Provider Demographics
NPI:1710129226
Name:WICKHAM, INGRID DELANEY (DPT)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:DELANEY
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 TROY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3103
Mailing Address - Country:US
Mailing Address - Phone:718-282-4636
Mailing Address - Fax:718-282-4636
Practice Address - Street 1:845 TROY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3103
Practice Address - Country:US
Practice Address - Phone:718-282-4636
Practice Address - Fax:718-282-4636
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017018-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist