Provider Demographics
NPI:1750566139
Name:BEANBLOSSOM, ALICIA JOY (LMT)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:JOY
Last Name:BEANBLOSSOM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:JOY
Other - Last Name:BEARCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:6853 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-6843
Mailing Address - Country:US
Mailing Address - Phone:623-826-9116
Mailing Address - Fax:
Practice Address - Street 1:6853 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-6843
Practice Address - Country:US
Practice Address - Phone:623-826-9116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06797208100000X
IA03882208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation