Provider Demographics
NPI:1023466612
Name:BREUER, ALICIA ANN (PTA)
Entity type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:ANN
Last Name:BREUER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:ANN
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:23601 S 433RD WEST AVE
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:OK
Mailing Address - Zip Code:74028-2466
Mailing Address - Country:US
Mailing Address - Phone:918-805-0480
Mailing Address - Fax:
Practice Address - Street 1:12899 E 76TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4021
Practice Address - Country:US
Practice Address - Phone:918-272-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1355225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant