Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 1079937 | TX |
Y | 225100000X | Physical Therapist | 11-04451 | KS |
NPI | 1003169301 |
---|---|
Provider Name | Alice Chiedzo Hakata |
First Address | Mansfield, TX 76063-4800 |
Second Address | Wichita, KS 67226 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2012 |
Last Update Date | 24/10/2012 |