Provider Demographics
NPI:1922643089
Name:WICKERT, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WICKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 DARTMOUTH DR
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-2322
Mailing Address - Country:US
Mailing Address - Phone:347-552-2371
Mailing Address - Fax:
Practice Address - Street 1:67A MOUNTAIN BLVD EXT.
Practice Address - Street 2:1ST FLOOR, UNIT B
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5626
Practice Address - Country:US
Practice Address - Phone:908-873-6337
Practice Address - Fax:908-332-5668
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032797235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist