Provider Demographics
NPI:1356408876
Name:WICKWIRE, MARCIA L (MPT)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:L
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9803 BATEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CRANESVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16410-1701
Mailing Address - Country:US
Mailing Address - Phone:814-460-6706
Mailing Address - Fax:
Practice Address - Street 1:2515 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4955
Practice Address - Country:US
Practice Address - Phone:440-997-6680
Practice Address - Fax:440-997-6311
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-011081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist