Provider Demographics
NPI:1396766812
Name:WYKES, MARSHA R (PT, OCS, CERT MDT)
Entity type:Individual
Prefix:
First Name:MARSHA
Middle Name:R
Last Name:WYKES
Suffix:
Gender:F
Credentials:PT, OCS, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-0727
Mailing Address - Country:US
Mailing Address - Phone:603-643-7788
Mailing Address - Fax:603-643-0022
Practice Address - Street 1:112 ETNA RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1454
Practice Address - Country:US
Practice Address - Phone:603-643-7788
Practice Address - Fax:603-643-0022
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30397715Medicaid
VT1016880Medicaid
NH001273001OtherMEDICARE PTAN