Provider Demographics
NPI:1770922411
Name:TICE, CHRISTINA ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:ANN
Last Name:TICE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:ANN
Other - Last Name:MAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16903 W MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1509
Mailing Address - Country:US
Mailing Address - Phone:808-291-0656
Mailing Address - Fax:
Practice Address - Street 1:14260 S DENNY BLVD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9448
Practice Address - Country:US
Practice Address - Phone:623-537-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-16
Last Update Date:2013-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8919A225200000X
CA9794225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant