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General NPI Number Information
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NPI Number | 1114502911
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Entity Type | Individual
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Provider Name | ALICIA M DIRKSEN LMT
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Gender | Female
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Dates
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Enumeration Date | 03/12/2021
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 2536 FARRAGUT DR
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City | SPRINGFIELD
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State | IL
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Zip | 62704-1540
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Country | US
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Telephone | 217-971-7647
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Fax |
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Provider Business Mailing Address
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Address Line | 2944 FLOWERBROOK CT
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City | SPRINGFIELD
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State | IL
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Zip | 62702-3321
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Country | US
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Telephone | 217-971-7647
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 227.021975
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 53526
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License Number State | CA
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