Provider Demographics
NPI:1740630441
Name:DAVID, ALICIA
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DAVID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRUSLY
Mailing Address - State:LA
Mailing Address - Zip Code:70719
Mailing Address - Country:US
Mailing Address - Phone:318-359-1766
Mailing Address - Fax:
Practice Address - Street 1:822 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRUSLY
Practice Address - State:LA
Practice Address - Zip Code:70719-2215
Practice Address - Country:US
Practice Address - Phone:225-931-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA8219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist