Healthcare Provider Details

I. General information

NPI: 1760329924
Provider Name (Legal Business Name): ALICIA JOHN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 E GATE BLVD
GARDEN CITY NY
11530-2124
US

IV. Provider business mailing address

50 MARION PEPE DR APT 50D
LODI NJ
07644-4074
US

V. Phone/Fax

Practice location:
  • Phone: 516-745-8050
  • Fax: 516-745-6766
Mailing address:
  • Phone: 201-757-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00255700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: