Healthcare Provider Details

I. General information

NPI: 1649215450
Provider Name (Legal Business Name): MITSUE ALICE WILCOXSON ATC, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N UNIVERSITY ST B63 MACKEY ARENA, PURDUE UNIVERSITY
WEST LAFAYETTE IN
47907-2070
US

IV. Provider business mailing address

1709 SUMMIT DR
WEST LAFAYETTE IN
47906-2229
US

V. Phone/Fax

Practice location:
  • Phone: 765-494-1703
  • Fax: 765-494-9899
Mailing address:
  • Phone: 765-497-0849
  • Fax: 765-494-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: