Healthcare Provider Details

I. General information

NPI: 1275725285
Provider Name (Legal Business Name): ALICIA HENDERSON ATC, OTC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 PEACHTREE RD NE STE 700
ATLANTA GA
30309-1414
US

IV. Provider business mailing address

2045 PEACHTREE RD NE STE 700
ATLANTA GA
30309-1414
US

V. Phone/Fax

Practice location:
  • Phone: 404-355-0743
  • Fax:
Mailing address:
  • Phone: 404-355-0743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001429
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: