Healthcare Provider Details

I. General information

NPI: 1568736551
Provider Name (Legal Business Name): ALICIA A EBERSOLE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2012
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WEST ST
NUNDA NY
14517-9685
US

IV. Provider business mailing address

PO BOX 613
NUNDA NY
14517-0613
US

V. Phone/Fax

Practice location:
  • Phone: 585-468-2020
  • Fax: 585-468-5001
Mailing address:
  • Phone: 585-519-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number022762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: