Provider Demographics
NPI:1245739051
Name:ANDERSON, ALLYSSA (SLP)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4821 SECTION LINE RD
Mailing Address - Street 2:
Mailing Address - City:LAONA
Mailing Address - State:WI
Mailing Address - Zip Code:54541-9245
Mailing Address - Country:US
Mailing Address - Phone:715-889-3282
Mailing Address - Fax:
Practice Address - Street 1:3576 NUROC LANE
Practice Address - Street 2:
Practice Address - City:LAONA
Practice Address - State:WI
Practice Address - Zip Code:54541
Practice Address - Country:US
Practice Address - Phone:715-674-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4578235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist