Provider Demographics
NPI:1114394004
Name:KELLER, ALYSSA RAE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:RAE
Last Name:KELLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:ALYSSA
Other - Middle Name:RAE
Other - Last Name:SONESEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3500
Mailing Address - Country:US
Mailing Address - Phone:307-431-6187
Mailing Address - Fax:
Practice Address - Street 1:120 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3637
Practice Address - Country:US
Practice Address - Phone:307-347-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0858225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant