Provider Demographics
NPI:1093451445
Name:TANK, ALYSSA LYNN
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:TANK
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 1:1033 PAR DR
Mailing Address - Street 2:
Mailing Address - City:WEIDMAN
Mailing Address - State:MI
Mailing Address - Zip Code:48893-9338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1524 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2933
Practice Address - Country:US
Practice Address - Phone:989-854-8334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician