Basic Information
| Provider Information | |||||||||
| NPI: | 1053513754 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WOLF | ||||||||
| FirstName: | FONDA | ||||||||
| MiddleName: | SYCHE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25459 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | CALCIUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136162188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5713342410 | ||||||||
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| Practice Location | |||||||||
| Address1: | 830 WASHINGTON STREET | ||||||||
| Address2: | SAMARITAN MEDICAL CENTER | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157854088 | ||||||||
| FaxNumber: | 3157864847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 02/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 033521 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 004067 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.