Provider Demographics
NPI:1003931809
Name:STEVENS, ALISIA DAWN (OT)
Entity Type:Individual
Prefix:
First Name:ALISIA
Middle Name:DAWN
Last Name:STEVENS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33
Mailing Address - Street 2:4820 BANDANA ROAD
Mailing Address - City:BANDANA
Mailing Address - State:KY
Mailing Address - Zip Code:42022-0033
Mailing Address - Country:US
Mailing Address - Phone:270-224-2065
Mailing Address - Fax:
Practice Address - Street 1:4820 BANDANA ROAD
Practice Address - Street 2:
Practice Address - City:BANDANA
Practice Address - State:KY
Practice Address - Zip Code:42022
Practice Address - Country:US
Practice Address - Phone:270-224-2065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY133572225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY133572OtherKENTUCKY STATE LICENSE