Provider Demographics
NPI:1003169301
Name:HAKATA, ALICE CHIEDZO (PT MED)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:CHIEDZO
Last Name:HAKATA
Suffix:
Gender:F
Credentials:PT MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SAINT ERIC DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2828 N. GOVERNEOUR, LARKSFIELD PLACE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226
Practice Address - Country:US
Practice Address - Phone:316-636-1111
Practice Address - Fax:316-858-3971
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-04451225100000X
TX1079937225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist