Healthcare Provider Details

I. General information

NPI: 1679870539
Provider Name (Legal Business Name): ALICIA WALL ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date: 04/06/2026
Reactivation Date: 06/19/2026

III. Provider practice location address

401 W MOHAWK DR
TOMAHAWK WI
54487-2274
US

IV. Provider business mailing address

401 W MOHAWK DR
TOMAHAWK WI
54487-2274
US

V. Phone/Fax

Practice location:
  • Phone: 715-453-7740
  • Fax: 715-453-7717
Mailing address:
  • Phone: 715-453-7740
  • Fax: 715-453-7717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5527-26
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1229-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: