Provider Demographics
NPI:1619454089
Name:MACKAY, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:MACKAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 N SAM HOUSTON PKWY W STE 240
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77086-1466
Mailing Address - Country:US
Mailing Address - Phone:817-292-8787
Mailing Address - Fax:817-789-6849
Practice Address - Street 1:4100 N SAM HOUSTON PKWY W STE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77086-1466
Practice Address - Country:US
Practice Address - Phone:817-292-8787
Practice Address - Fax:817-789-6849
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2140873225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant