Provider Demographics
NPI:1174607089
Name:WALICKY, STEPHEN BARRY (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BARRY
Last Name:WALICKY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 CONCORD WAY
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2235
Mailing Address - Country:US
Mailing Address - Phone:732-255-8423
Mailing Address - Fax:
Practice Address - Street 1:1000 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-2606
Practice Address - Country:US
Practice Address - Phone:732-671-5515
Practice Address - Fax:732-671-5647
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC2180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJWA453653Medicare ID - Type Unspecified