Healthcare Provider Details

I. General information

NPI: 1972051217
Provider Name (Legal Business Name): ALISSA VIDOVICH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BRIGHTWATER DR
MYRTLE BEACH SC
29579-8275
US

IV. Provider business mailing address

649 SWINFORD DR
MYRTLE BEACH SC
29588-4645
US

V. Phone/Fax

Practice location:
  • Phone: 843-236-3579
  • Fax:
Mailing address:
  • Phone: 856-332-3722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4794
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: