Provider Demographics
NPI:1114502911
Name:DIRKSEN, ALICIA M (LMT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:DIRKSEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2944 FLOWERBROOK CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3321
Mailing Address - Country:US
Mailing Address - Phone:217-971-7647
Mailing Address - Fax:
Practice Address - Street 1:2536 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1540
Practice Address - Country:US
Practice Address - Phone:217-971-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.021975225700000X
CA53526225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist