Basic Information
| Provider Information | |||||||||
| NPI: | 1255372082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKER | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT, OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217738155 | ||||||||
| FaxNumber: | 3217738154 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 S PATRICK DR | ||||||||
| Address2: | STE 3 | ||||||||
| City: | INDIAN HARBOUR BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329374400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217738155 | ||||||||
| FaxNumber: | 3217738154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT20840 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT-20840 | 01 | FL | STATE OF FL. PT LICENSE NUMBER | OTHER | K-3234 | 01 | FL | BEACHSIDE P.T. GROUP NUMBER | OTHER |