Provider Demographics
NPI:1700903507
Name:DEBORD, ALICIA ANGELINE (PT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANGELINE
Last Name:DEBORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:ANGELINE
Other - Last Name:MAXWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:451 HERITAGE OAKS LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-9837
Mailing Address - Country:US
Mailing Address - Phone:336-263-5022
Mailing Address - Fax:
Practice Address - Street 1:336 DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5008
Practice Address - Country:US
Practice Address - Phone:828-268-9043
Practice Address - Fax:828-268-9045
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3400051Medicaid