Provider Demographics
NPI:1932980851
Name:WICKLIFF, DANIEL GLENN
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GLENN
Last Name:WICKLIFF
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 1:1211 UNION AVE STE 195
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6603
Mailing Address - Country:US
Mailing Address - Phone:901-759-3280
Mailing Address - Fax:
Practice Address - Street 1:1211 UNION AVE STE 195
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6603
Practice Address - Country:US
Practice Address - Phone:901-759-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000011788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist