Provider Demographics
NPI:1376312918
Name:BLACK, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:BLACK
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 1:1735 SE MADISON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3752
Mailing Address - Country:US
Mailing Address - Phone:503-851-8717
Mailing Address - Fax:
Practice Address - Street 1:3944 N MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1163
Practice Address - Country:US
Practice Address - Phone:503-517-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18673225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist