Provider Demographics
NPI:1104166545
Name:TILLINGHAST, ALYSSA (OTR/L)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:TILLINGHAST
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LAKEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:EASTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11941-1208
Mailing Address - Country:US
Mailing Address - Phone:631-905-6211
Mailing Address - Fax:
Practice Address - Street 1:10 LAKEVIEW CT
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:NY
Practice Address - Zip Code:11941-1208
Practice Address - Country:US
Practice Address - Phone:631-905-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63 017877225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist