Provider Demographics
NPI:1265790240
Name:CLARK, ALICIA L (DPT)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:DELAZIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:4805 BIRNEY AVE
Mailing Address - Street 2:
Mailing Address - City:MOOSIC
Mailing Address - State:PA
Mailing Address - Zip Code:18507-1231
Mailing Address - Country:US
Mailing Address - Phone:570-774-4200
Mailing Address - Fax:
Practice Address - Street 1:4805 BIRNEY AVE
Practice Address - Street 2:
Practice Address - City:MOOSIC
Practice Address - State:PA
Practice Address - Zip Code:18507-1231
Practice Address - Country:US
Practice Address - Phone:570-774-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist