Provider Demographics
NPI:1922387745
Name:WICKSTROM, RICHARD JOSEPH (PT, DPT, CPE, CDMS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOSEPH
Last Name:WICKSTROM
Suffix:
Gender:M
Credentials:PT, DPT, CPE, CDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7665 MONARCH CT
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-2497
Mailing Address - Country:US
Mailing Address - Phone:513-821-7420
Mailing Address - Fax:513-672-2552
Practice Address - Street 1:7665 MONARCH CT
Practice Address - Street 2:SUITE 109
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-2497
Practice Address - Country:US
Practice Address - Phone:513-821-7420
Practice Address - Fax:513-672-2552
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35822251E1200X
KY0016902251E1200X
IN05009555A2251E1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics