Provider Demographics
NPI:1053717124
Name:WICKI, BENJAMIN (DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WICKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CHURCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1658
Mailing Address - Country:US
Mailing Address - Phone:203-426-8449
Mailing Address - Fax:203-426-8980
Practice Address - Street 1:30 CHURCH HILL RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-1658
Practice Address - Country:US
Practice Address - Phone:203-426-8449
Practice Address - Fax:203-426-8980
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist