Provider Demographics
NPI:1225893662
Name:THACKERAY, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:THACKERAY
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:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:HENEFER
Mailing Address - State:UT
Mailing Address - Zip Code:84033-0376
Mailing Address - Country:US
Mailing Address - Phone:435-659-4851
Mailing Address - Fax:
Practice Address - Street 1:1858 W 5150 S STE 504
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-3064
Practice Address - Country:US
Practice Address - Phone:801-255-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health