Healthcare Provider Details

I. General information

NPI: 1831068279
Provider Name (Legal Business Name): SOURCE PELVIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6691 SHANGRI LA CIR
ANCHORAGE AK
99516-5070
US

IV. Provider business mailing address

PO BOX 110746
ANCHORAGE AK
99511-0746
US

V. Phone/Fax

Practice location:
  • Phone: 817-808-9550
  • Fax:
Mailing address:
  • Phone: 817-808-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRA HOLLY DONALDSON
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L, CSOT
Phone: 817-808-9550