Provider Demographics
NPI:1962068254
Name:ALICANDO, DARA FAYE GONZALES (PT)
Entity type:Individual
Prefix:
First Name:DARA FAYE
Middle Name:GONZALES
Last Name:ALICANDO
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 1:20 TILTON CT
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-5183
Mailing Address - Country:US
Mailing Address - Phone:443-844-6789
Mailing Address - Fax:443-632-0690
Practice Address - Street 1:12230 ROUNDWOOD RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-3233
Practice Address - Country:US
Practice Address - Phone:410-252-0880
Practice Address - Fax:443-632-0690
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22877225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist