Provider Demographics
NPI:1225557986
Name:ROTENBERRY, ALYSSA BROOKE (ATC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:BROOKE
Last Name:ROTENBERRY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 MARION ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457
Practice Address - Country:US
Practice Address - Phone:318-357-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA1255579862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALNAOtherBCBS