Provider Demographics
NPI:1063798791
Name:NIEDERLOVA, ALENA (PT)
Entity type:Individual
Prefix:
First Name:ALENA
Middle Name:
Last Name:NIEDERLOVA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5106 MAYFAIR PARK CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2727
Mailing Address - Country:US
Mailing Address - Phone:813-907-7879
Mailing Address - Fax:813-994-3080
Practice Address - Street 1:17419 BRIDGE HILL CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3599
Practice Address - Country:US
Practice Address - Phone:813-907-7879
Practice Address - Fax:813-994-3080
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8697225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT8697OtherPT8697