Provider Demographics
NPI:1447899562
Name:HANSEN, ALYSSA FOSTER
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:FOSTER
Last Name:HANSEN
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 1:233 N ASBURY ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2130
Mailing Address - Country:US
Mailing Address - Phone:208-600-8085
Mailing Address - Fax:
Practice Address - Street 1:116 E 3RD ST # 209
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-4318
Practice Address - Country:US
Practice Address - Phone:208-600-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist