Provider Demographics
NPI:1285645127
Name:RAJA, ALICE ELAINE (PT)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:ELAINE
Last Name:RAJA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4911
Mailing Address - Country:US
Mailing Address - Phone:757-436-6913
Mailing Address - Fax:757-547-2544
Practice Address - Street 1:200 MEDICAL PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4911
Practice Address - Country:US
Practice Address - Phone:757-436-6913
Practice Address - Fax:757-547-2544
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9401164Medicaid
VA9401164Medicaid