Provider Demographics
NPI:1447863055
Name:DAVIS, ALYSSA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N EISENHOWER DR APT M3
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5147
Mailing Address - Country:US
Mailing Address - Phone:620-481-3168
Mailing Address - Fax:
Practice Address - Street 1:811 GROVE ST
Practice Address - Street 2:
Practice Address - City:BALDWIN CITY
Practice Address - State:KS
Practice Address - Zip Code:66006-9204
Practice Address - Country:US
Practice Address - Phone:785-594-2909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-05379224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant