Provider Demographics
NPI:1306355052
Name:STOFFEL, ALYSIA MARIE
Entity type:Individual
Prefix:
First Name:ALYSIA
Middle Name:MARIE
Last Name:STOFFEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSIA
Other - Middle Name:MARIE
Other - Last Name:SARGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24
Mailing Address - Street 2:
Mailing Address - City:WILLISVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62997-0024
Mailing Address - Country:US
Mailing Address - Phone:618-497-2564
Mailing Address - Fax:
Practice Address - Street 1:1725 SHOMAKER DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2507
Practice Address - Country:US
Practice Address - Phone:618-687-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty