Provider Demographics
NPI:1477102259
Name:PALMER, ALYSIA DIANE
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:DIANE
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSIA
Other - Middle Name:DIANE
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CASAC-T
Mailing Address - Street 1:133 KENNEDY RD
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-1124
Mailing Address - Country:US
Mailing Address - Phone:607-201-5395
Mailing Address - Fax:
Practice Address - Street 1:1062 STATE ROUTE 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-3209
Practice Address - Country:US
Practice Address - Phone:607-689-8114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33383101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)