Provider Demographics
NPI:1245805027
Name:CARTER, ALYSSA A (PTA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:A
Last Name:CARTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2929
Mailing Address - Country:US
Mailing Address - Phone:630-800-8143
Mailing Address - Fax:
Practice Address - Street 1:4058 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-5202
Practice Address - Country:US
Practice Address - Phone:630-793-4464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006494225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant