Provider Demographics
NPI:1417609926
Name:HERBAUGH, ALYSSA GRACE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GRACE
Last Name:HERBAUGH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 RIVERCHASE BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37115-2061
Mailing Address - Country:US
Mailing Address - Phone:973-970-0564
Mailing Address - Fax:
Practice Address - Street 1:131 SAUNDERSVILLE RD STE 160
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-8940
Practice Address - Country:US
Practice Address - Phone:615-488-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6401225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist