Provider Demographics
NPI:1255372082
Name:WICKER, CHRISTOPHER M (PT, DPT, OTR/L)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:M
Last Name:WICKER
Suffix:
Gender:M
Credentials:PT, DPT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 S PATRICK DR
Mailing Address - Street 2:STE 3
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4400
Mailing Address - Country:US
Mailing Address - Phone:321-773-8155
Mailing Address - Fax:321-773-8154
Practice Address - Street 1:2030 S PATRICK DR
Practice Address - Street 2:STE 3
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4400
Practice Address - Country:US
Practice Address - Phone:321-773-8155
Practice Address - Fax:321-773-8154
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT-20840OtherSTATE OF FL. PT LICENSE NUMBER
FLK-3234OtherBEACHSIDE P.T. GROUP NUMBER
FLU0980ZMedicare PIN