Provider Demographics
NPI:1447261516
Name:WYCOFF, CAROL M (PT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:M
Last Name:WYCOFF
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 1:3922 S FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4812 E 33RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2038
Practice Address - Country:US
Practice Address - Phone:918-622-4126
Practice Address - Fax:918-270-2398
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5580476OtherAETNA LEGACY
OK100833610AMedicaid
100833610AOtherMEDICAID LEGACY
243323903OtherMEDICARE LEGACY
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$$$$$$$$$002OtherBCBS LEGACY