Provider Demographics
NPI:1912567165
Name:POLSTON, ALICIA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:POLSTON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 LADD LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-2466
Mailing Address - Country:US
Mailing Address - Phone:503-577-0746
Mailing Address - Fax:
Practice Address - Street 1:1917 ABBOTT RD STE 200
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3449
Practice Address - Country:US
Practice Address - Phone:907-279-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist