Provider Demographics
NPI:1093200685
Name:VANG, ALYSSA FUABKAAJ
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:FUABKAAJ
Last Name:VANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SW ARCTIC DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-9447
Mailing Address - Country:US
Mailing Address - Phone:503-718-7569
Mailing Address - Fax:
Practice Address - Street 1:6200 SW ARCTIC DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-9447
Practice Address - Country:US
Practice Address - Phone:503-718-7569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3927174103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst