Provider Demographics
NPI:1063208171
Name:ISRAEL, ALYSSA MAE KOKTAVY (MSW, LGSW)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MAE KOKTAVY
Last Name:ISRAEL
Suffix:
Gender:
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2918
Mailing Address - Country:US
Mailing Address - Phone:507-581-2510
Mailing Address - Fax:
Practice Address - Street 1:10248 E OLSON RD
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-8184
Practice Address - Country:US
Practice Address - Phone:218-666-5221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN342881041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool