Provider Demographics
NPI:1104261692
Name:OWEN, ALICIA (PTA)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:
Last Name:OWEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:GA
Mailing Address - Zip Code:31803-9505
Mailing Address - Country:US
Mailing Address - Phone:229-942-6901
Mailing Address - Fax:
Practice Address - Street 1:6600 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:BLDG 400 STE 123
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6773
Practice Address - Country:US
Practice Address - Phone:678-587-9922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002238225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant