Provider Demographics
NPI:1710270178
Name:WICKLINE, KALYN MASHAE (MSOT)
Entity Type:Individual
Prefix:
First Name:KALYN
Middle Name:MASHAE
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:MSOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 GREGORY AVE
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-5814
Mailing Address - Country:US
Mailing Address - Phone:860-417-8158
Mailing Address - Fax:
Practice Address - Street 1:600 GREGORY AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-5814
Practice Address - Country:US
Practice Address - Phone:860-417-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016760225X00000X
NJ46TR00605700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist