Provider Demographics
NPI:1265640395
Name:OBERQUELL, ALICIA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:OBERQUELL
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 1:72 SALISBURY ST
Mailing Address - Street 2:#1
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-3161
Mailing Address - Country:US
Mailing Address - Phone:360-471-6743
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8324
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7999225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant