Provider Demographics
NPI:1568012326
Name:CULLEN, ALYSIA HARRINGTON CROCKER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ALYSIA
Middle Name:HARRINGTON CROCKER
Last Name:CULLEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LISSA
Other - Middle Name:CROCKER
Other - Last Name:CULLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PSC 561 BOX 7562
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96310-0076
Mailing Address - Country:US
Mailing Address - Phone:917-886-5966
Mailing Address - Fax:
Practice Address - Street 1:9427A ORANGE BLOSSOM TR.
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96310-0076
Practice Address - Country:US
Practice Address - Phone:917-886-5966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-13
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist