Provider Demographics
NPI:1215601711
Name:MARCUSSEN, ALICIA YUKA (OTR/L)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:YUKA
Last Name:MARCUSSEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8943 JUSTONIAN WAY
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-9579
Mailing Address - Country:US
Mailing Address - Phone:517-763-1068
Mailing Address - Fax:
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-9330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOT-1584225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist