Provider Demographics
NPI:1093202970
Name:GLOVER, ALYSSA G (PT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:G
Last Name:GLOVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3630 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-2224
Mailing Address - Country:US
Mailing Address - Phone:318-367-0604
Mailing Address - Fax:318-367-2678
Practice Address - Street 1:3630 FRONT ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-2224
Practice Address - Country:US
Practice Address - Phone:318-367-0604
Practice Address - Fax:318-367-2678
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA09573OtherPHYSICAL THERAPY LICENSE