Provider Demographics
NPI:1609766013
Name:TICZON, WILYSA BENDEBEL (RPT)
Entity type:Individual
Prefix:
First Name:WILYSA
Middle Name:BENDEBEL
Last Name:TICZON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CAROLYN RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-9402
Mailing Address - Country:US
Mailing Address - Phone:908-937-3984
Mailing Address - Fax:908-937-3984
Practice Address - Street 1:207 CAROLYN RD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-9402
Practice Address - Country:US
Practice Address - Phone:908-937-3984
Practice Address - Fax:908-937-3984
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01345200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist