Basic Information
| Provider Information | |||||||||
| NPI: | 1205497484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUSTICE | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 918 E MEAD AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989033720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094531344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 918 E MEAD AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989033720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094531344 | ||||||||
| FaxNumber: | 5094532981 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2019 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP |
No ID Information.