Provider Demographics
NPI:1922606862
Name:BOLSHAKOVA, ALENA (PTA)
Entity Type:Individual
Prefix:
First Name:ALENA
Middle Name:
Last Name:BOLSHAKOVA
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 1:3120 SUN DRENCHED PATH
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78732-1950
Mailing Address - Country:US
Mailing Address - Phone:404-493-1628
Mailing Address - Fax:
Practice Address - Street 1:3120 SUN DRENCHED PATH
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78732-1950
Practice Address - Country:US
Practice Address - Phone:404-493-1628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2157760225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty