Provider Demographics
NPI:1437547353
Name:THORNBURG, ALICIA (MS, ATC)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:THORNBURG
Suffix:
Gender:F
Credentials:MS, ATC
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 4049
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39058-0001
Mailing Address - Country:US
Mailing Address - Phone:601-925-7361
Mailing Address - Fax:
Practice Address - Street 1:200 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4026
Practice Address - Country:US
Practice Address - Phone:601-925-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT05272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer