Provider Demographics
NPI:1053513754
Name:WOLF, FONDA SYCHE (PT)
Entity type:Individual
Prefix:MRS
First Name:FONDA
Middle Name:SYCHE
Last Name:WOLF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25459 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:CALCIUM
Mailing Address - State:NY
Mailing Address - Zip Code:13616-2188
Mailing Address - Country:US
Mailing Address - Phone:571-334-2410
Mailing Address - Fax:
Practice Address - Street 1:830 WASHINGTON STREET
Practice Address - Street 2:SAMARITAN MEDICAL CENTER
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-785-4088
Practice Address - Fax:315-786-4847
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033521225100000X
GA004067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty