Provider Demographics
NPI:1497421440
Name:MANGES, ALYSSA ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:MANGES
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 1:435 ASPEN DR APT 8
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5190
Mailing Address - Country:US
Mailing Address - Phone:419-512-1368
Mailing Address - Fax:
Practice Address - Street 1:900 ROUND VALLEY DR STE 200
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-658-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9086925-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist