Provider Demographics
NPI:1063830255
Name:UPSHAW, ALYSIA
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:
Last Name:UPSHAW
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 1:2604 NW 164TH TER
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1244
Mailing Address - Country:US
Mailing Address - Phone:405-788-1863
Mailing Address - Fax:
Practice Address - Street 1:2604 NW 164TH TER
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1244
Practice Address - Country:US
Practice Address - Phone:405-788-1863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor