Provider Demographics
NPI:1598990491
Name:WALLICK, MINDY SUE (MS, ATC)
Entity type:Individual
Prefix:MS
First Name:MINDY
Middle Name:SUE
Last Name:WALLICK
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BRENNER ST
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17551-1411
Mailing Address - Country:US
Mailing Address - Phone:717-380-7000
Mailing Address - Fax:
Practice Address - Street 1:2125 NOLL DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-7606
Practice Address - Country:US
Practice Address - Phone:717-380-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0044502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer