Provider Demographics
NPI:1285292862
Name:JOHNSON, ALICIA BLACKHAM (DPT)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:BLACKHAM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:
Other - Last Name:BLACKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7630 WISTAR VILLAGE DR APT C
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3524
Mailing Address - Country:US
Mailing Address - Phone:702-994-6790
Mailing Address - Fax:
Practice Address - Street 1:300B TEMPLE LAKE DR STE 1
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2973
Practice Address - Country:US
Practice Address - Phone:804-524-9036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11099512-2401225100000X
VA2305212681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist