Provider Demographics
NPI:1396125522
Name:CLARK, ALICIA KOHN
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:KOHN
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 JEFFERSON DAVIS HIGHWAY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-9411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-4220
Practice Address - Country:US
Practice Address - Phone:984-974-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist