Provider Demographics
NPI:1528798667
Name:IDE, ALLYSE MARIE (TLLP)
Entity type:Individual
Prefix:
First Name:ALLYSE
Middle Name:MARIE
Last Name:IDE
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PLEASANT ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2279
Mailing Address - Country:US
Mailing Address - Phone:269-982-3832
Mailing Address - Fax:
Practice Address - Street 1:830 PLEASANT ST STE 201
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2279
Practice Address - Country:US
Practice Address - Phone:269-982-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009552103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical