Provider Demographics
NPI:1992554083
Name:GOODWIN, ALYSSA MARY (OTR)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARY
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:MARY
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:91 MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-3110
Mailing Address - Country:US
Mailing Address - Phone:508-212-5367
Mailing Address - Fax:
Practice Address - Street 1:175 GROVE ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-7253
Practice Address - Country:US
Practice Address - Phone:781-848-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12728225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist