Basic Information
| Provider Information | |||||||||
| NPI: | 1154675775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACDONALD | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5835 SE OGDEN ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972067551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3212137930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10014 N RODNEY PARHAM RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722275598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012245454 | ||||||||
| FaxNumber: | 5012245460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2012 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-27905 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 63813 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT 4260 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 229940721 | 05 | AR | MEDICAID |