Provider Demographics
NPI:1982301883
Name:DETWILER, ALEXANDRIA (PTA)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:DETWILER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ALEXANDRIA
Other - Middle Name:DETWILER
Other - Last Name:PROVENCIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:4601 SPICEWOOD SPRINGS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4601 SPICEWOOD SPRINGS RD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8598
Practice Address - Country:US
Practice Address - Phone:512-345-4664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2139077208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation