Healthcare Provider Details

I. General information

NPI: 1285292862
Provider Name (Legal Business Name): ALICIA BLACKHAM JOHNSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALICIA BLACKHAM

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300B TEMPLE LAKE DR STE 1
COLONIAL HEIGHTS VA
23834-2973
US

IV. Provider business mailing address

7630 WISTAR VILLAGE DR APT C
HENRICO VA
23228-3524
US

V. Phone/Fax

Practice location:
  • Phone: 804-524-9036
  • Fax:
Mailing address:
  • Phone: 702-994-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11099512-2401
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305212681
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: