Provider Demographics
NPI:1932651213
Name:STANDISH, ALICIA (PTA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:STANDISH
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 1:2626 GLENWOOD AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-1367
Mailing Address - Country:US
Mailing Address - Phone:984-444-9903
Mailing Address - Fax:
Practice Address - Street 1:2626 GLENWOOD AVE STE 160
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-1367
Practice Address - Country:US
Practice Address - Phone:984-444-9903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2867251E00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No252Y00000XAgenciesEarly Intervention Provider Agency