Provider Demographics
NPI:1417014028
Name:EWEN, ALYCE MAY (MPT)
Entity Type:Individual
Prefix:
First Name:ALYCE
Middle Name:MAY
Last Name:EWEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6450
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93456-6450
Mailing Address - Country:US
Mailing Address - Phone:805-928-4465
Mailing Address - Fax:805-928-7935
Practice Address - Street 1:2530 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-8200
Practice Address - Country:US
Practice Address - Phone:805-928-4465
Practice Address - Fax:805-928-7935
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT259000OtherBLUE SHIELD
CAPT025900Medicaid
CA0PT259000OtherBLUE SHIELD