Provider Demographics
NPI:1861848384
Name:WYSOCKI, TRENT
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 KITCHENS ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:FALLING WATERS
Mailing Address - State:WV
Mailing Address - Zip Code:25419-3872
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 KITCHENS ORCHARD RD
Practice Address - Street 2:
Practice Address - City:FALLING WATERS
Practice Address - State:WV
Practice Address - Zip Code:25419-3872
Practice Address - Country:US
Practice Address - Phone:304-575-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2001-0782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist