Basic Information
| Provider Information | |||||||||
| NPI: | 1992327704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYSOCKI | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 823 COBBLESTONE BLVD APT 204 | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224016671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103310668 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 PARK HILL DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403687300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2020 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119008503 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.