Provider Demographics
NPI:1760865125
Name:SHOUP, ALICIA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:SHOUP
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:MARIE
Other - Last Name:KURTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:10165 E HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3327
Mailing Address - Country:US
Mailing Address - Phone:480-354-5424
Mailing Address - Fax:
Practice Address - Street 1:10165 E HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3327
Practice Address - Country:US
Practice Address - Phone:480-354-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADAPT000189225100000X
AZ11544PT2251X0800X
PAPT007130L2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist