Provider Demographics
NPI:1053704080
Name:WICKER, MARYAN NADER (DPT)
Entity type:Individual
Prefix:
First Name:MARYAN
Middle Name:NADER
Last Name:WICKER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9933 TRAVERTINE TRL
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7654
Mailing Address - Country:US
Mailing Address - Phone:551-221-1983
Mailing Address - Fax:
Practice Address - Street 1:626 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-3206
Practice Address - Country:US
Practice Address - Phone:201-372-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-16
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01602700225100000X
NCP20298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist