Provider Demographics
NPI:1346890936
Name:WOOD, ALYSE DANIELE (OTRL)
Entity Type:Individual
Prefix:
First Name:ALYSE
Middle Name:DANIELE
Last Name:WOOD
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6340 E MAIN ST APT 301
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-4680
Mailing Address - Country:US
Mailing Address - Phone:989-292-9634
Mailing Address - Fax:
Practice Address - Street 1:10215 BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8001
Practice Address - Country:US
Practice Address - Phone:219-663-8948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31006866A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist