Healthcare Provider Details

I. General information

NPI: 1285220996
Provider Name (Legal Business Name): ALICIA WOLLER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 LINCOLN AVE
STEAMBOAT SPRINGS CO
80487-8048
US

IV. Provider business mailing address

PO BOX 776056
STEAMBOAT SPRINGS CO
80477-6056
US

V. Phone/Fax

Practice location:
  • Phone: 970-870-3484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0016740
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: