Provider Demographics
NPI:1982913166
Name:DEZELL, ALYCIA MARIE (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:ALYCIA
Middle Name:MARIE
Last Name:DEZELL
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 STATE HIGHWAY 68
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-4403
Mailing Address - Country:US
Mailing Address - Phone:315-393-3070
Mailing Address - Fax:315-393-3014
Practice Address - Street 1:8101 STATE HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-4403
Practice Address - Country:US
Practice Address - Phone:315-393-3070
Practice Address - Fax:315-393-3014
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015947-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015947-1OtherOCCUPATIONAL THERAPIST