Provider Demographics
NPI:1962971895
Name:OTT, ALYSSA JASMINE (MT-BC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JASMINE
Last Name:OTT
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4524 N WOLCOTT AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5240
Mailing Address - Country:US
Mailing Address - Phone:972-965-4366
Mailing Address - Fax:
Practice Address - Street 1:1350 E TOUHY AVE # 130
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-3303
Practice Address - Country:US
Practice Address - Phone:815-812-2355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13136225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist