Provider Demographics
NPI:1639208838
Name:ARCHER, ALICE C (PTA)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:C
Last Name:ARCHER
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 1:135 UNAKA VIEW RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-5119
Mailing Address - Country:US
Mailing Address - Phone:423-928-1026
Mailing Address - Fax:
Practice Address - Street 1:629 W ELK AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2559
Practice Address - Country:US
Practice Address - Phone:423-722-2062
Practice Address - Fax:423-722-2063
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000002449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446517Medicaid
TN0446517Medicaid