Provider Demographics
NPI:1164026902
Name:WANTUCH, ALIA J (PTA)
Entity Type:Individual
Prefix:
First Name:ALIA
Middle Name:J
Last Name:WANTUCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 CREEKWATER BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4088
Mailing Address - Country:US
Mailing Address - Phone:386-871-4431
Mailing Address - Fax:
Practice Address - Street 1:4606 CLYDE MORRIS BLVD STE 1D
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-7453
Practice Address - Country:US
Practice Address - Phone:386-492-2986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30714225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant