Provider Demographics
NPI:1932474061
Name:WIKSTROM, SEBASTIAN
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:WIKSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N SWALLOWTAIL DR
Mailing Address - Street 2:APT 201
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-9623
Mailing Address - Country:US
Mailing Address - Phone:386-756-4395
Mailing Address - Fax:386-944-7202
Practice Address - Street 1:5535 S WILLIAMSON BLVD
Practice Address - Street 2:SUITE 774
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-8311
Practice Address - Country:US
Practice Address - Phone:386-756-4935
Practice Address - Fax:386-944-7202
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist