Provider Demographics
NPI:1114433356
Name:JOHNSON, ALYSSA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7058 N 850TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61238-9248
Mailing Address - Country:US
Mailing Address - Phone:309-525-0611
Mailing Address - Fax:
Practice Address - Street 1:2209 NORTHERN DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-2256
Practice Address - Country:US
Practice Address - Phone:319-243-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X, 103K00000X
WACB60799981106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician