Provider Demographics
NPI:1417322611
Name:BLACK, ALYSSA LEA (COTA)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:LEA
Last Name:BLACK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 S LAKELINE BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-4567
Mailing Address - Country:US
Mailing Address - Phone:512-219-0200
Mailing Address - Fax:
Practice Address - Street 1:2200 S LAKELINE BLVD
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-4567
Practice Address - Country:US
Practice Address - Phone:512-219-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209841172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker