Healthcare Provider Details

I. General information

NPI: 1396285540
Provider Name (Legal Business Name): ALEX CIVIL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8580 VERREE RD
PHILADELPHIA PA
19111-1370
US

IV. Provider business mailing address

685 RIVER AVE
LAKEWOOD NJ
08701-5288
US

V. Phone/Fax

Practice location:
  • Phone: 215-214-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number07597
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC015681
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: