Provider Demographics
NPI:1679870539
Name:WALL, ALICIA (ATC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:WALL
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54487-2274
Mailing Address - Country:US
Mailing Address - Phone:715-453-7740
Mailing Address - Fax:715-453-7717
Practice Address - Street 1:401 W MOHAWK DR
Practice Address - Street 2:
Practice Address - City:TOMAHAWK
Practice Address - State:WI
Practice Address - Zip Code:54487-2274
Practice Address - Country:US
Practice Address - Phone:715-453-7740
Practice Address - Fax:715-453-7717
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1229-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer