Provider Demographics
NPI:1073821591
Name:ALICEA, INGRID (COTA/L)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:ALICEA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 EAST MAPLE ST.
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720
Mailing Address - Country:US
Mailing Address - Phone:330-498-8239
Mailing Address - Fax:
Practice Address - Street 1:339 EAST MAPLE ST.
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720
Practice Address - Country:US
Practice Address - Phone:330-498-8239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2011-03-16
Deactivation Date:2010-12-23
Deactivation Code:
Reactivation Date:2011-03-09
Provider Licenses
StateLicense IDTaxonomies
OHOTA04431224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant