Provider Demographics
NPI:1083498273
Name:FRY, ALYSSA MARY
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARY
Last Name:FRY
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 1:3667 KEYSTONE AVE APT 532
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-2652
Mailing Address - Country:US
Mailing Address - Phone:719-355-5941
Mailing Address - Fax:
Practice Address - Street 1:12304 SANTA MONICA BLVD STE 364
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1542
Practice Address - Country:US
Practice Address - Phone:303-710-5631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist