Provider Demographics
NPI:1497136758
Name:MICELI, ALYSSA (DO)
Entity Type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:
Last Name:MICELI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43900 GARFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1137
Mailing Address - Country:US
Mailing Address - Phone:586-286-0112
Mailing Address - Fax:586-286-1241
Practice Address - Street 1:28333 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1687
Practice Address - Country:US
Practice Address - Phone:586-776-9770
Practice Address - Fax:586-776-9772
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT69652207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program