Provider Demographics
NPI:1104400175
Name:CLARK, ALYSSA (MT-BC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:THORP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MT-BC
Mailing Address - Street 1:245 N METRO DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 N METRO DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8572
Practice Address - Country:US
Practice Address - Phone:920-903-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12186225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12186OtherCBMT