Provider Demographics
NPI:1356570329
Name:EDELEN, ALIA ANTONUCCI-ALTER (DPT)
Entity type:Individual
Prefix:
First Name:ALIA
Middle Name:ANTONUCCI-ALTER
Last Name:EDELEN
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 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:570-550-0168
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:5838 SIX FORKS RD STE 300
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3893
Practice Address - Country:US
Practice Address - Phone:919-782-5954
Practice Address - Fax:919-890-5304
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist