Provider Demographics
NPI:1407606197
Name:ROYAL, ALYSSA DEBRA
Entity Type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:DEBRA
Last Name:ROYAL
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 1:6060 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1907
Mailing Address - Country:US
Mailing Address - Phone:317-815-5501
Mailing Address - Fax:
Practice Address - Street 1:15 PACELLA PARK DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-1780
Practice Address - Country:US
Practice Address - Phone:781-990-5797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALABA10000782103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst