Provider Demographics
NPI:1518658467
Name:DIVALERIO, ALEC
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:DIVALERIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 21ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-8904
Mailing Address - Country:US
Mailing Address - Phone:214-244-7613
Mailing Address - Fax:
Practice Address - Street 1:1600 SLEATER KINNEY RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2500
Practice Address - Country:US
Practice Address - Phone:360-456-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1376653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist