Provider Demographics
NPI:1972968329
Name:ANDERSON, ALYSSA (ATC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 W FOSTER AVE
Mailing Address - Street 2:BOX 25
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4823
Mailing Address - Country:US
Mailing Address - Phone:773-244-6221
Mailing Address - Fax:
Practice Address - Street 1:3225 W FOSTER AVE
Practice Address - Street 2:BOX 25
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4823
Practice Address - Country:US
Practice Address - Phone:773-244-6221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0038672255A2300X
OHAT. 0038832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer