Healthcare Provider Details

I. General information

NPI: 1609738020
Provider Name (Legal Business Name): ALICIA NICOLE WITHERSPOON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 HARVARD AVE
COLLEGE PARK GA
30337-3526
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TOWNSHIP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 404-835-4321
  • Fax: 404-835-4320
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018106
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: