Provider Demographics
NPI:1699550145
Name:KOSHEVATSKIY, ALICE KAY (PT)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:KAY
Last Name:KOSHEVATSKIY
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:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58784-0399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:701-628-3823
Practice Address - Street 1:615 6TH ST SE
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:ND
Practice Address - Zip Code:58784-4444
Practice Address - Country:US
Practice Address - Phone:701-628-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI5779225100000X
NDCP022489T225100000X
IL070027454225100000X
WI16427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist