Provider Demographics
NPI:1215435896
Name:SHIREK, ALYSSA A (OT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:A
Last Name:SHIREK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:A
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:3507 EVERGREEN RD N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1218
Mailing Address - Country:US
Mailing Address - Phone:701-261-4643
Mailing Address - Fax:701-365-8134
Practice Address - Street 1:102 W BEATON DR STE 105
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078
Practice Address - Country:US
Practice Address - Phone:701-261-4643
Practice Address - Fax:701-540-9044
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist