Basic Information
| Provider Information | |||||||||
| NPI: | 1750341129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WICK | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12400 ALCOY DR | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106298321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6012 S LINDEN RD | ||||||||
| Address2: | STE 15 | ||||||||
| City: | SWARTZ CREEK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106558244 | ||||||||
| FaxNumber: | 8106552192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501002417 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.