Provider Demographics
NPI:1568736551
Name:EBERSOLE, ALICIA A (PT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:A
Last Name:EBERSOLE
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:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:NUNDA
Mailing Address - State:NY
Mailing Address - Zip Code:14517-0613
Mailing Address - Country:US
Mailing Address - Phone:585-519-5050
Mailing Address - Fax:
Practice Address - Street 1:25 WEST ST
Practice Address - Street 2:
Practice Address - City:NUNDA
Practice Address - State:NY
Practice Address - Zip Code:14517-9685
Practice Address - Country:US
Practice Address - Phone:585-468-2020
Practice Address - Fax:585-468-5001
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist