Provider Demographics
NPI:1578004800
Name:FUSSELL, ALISA
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10131 HWY 53 W
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425
Mailing Address - Country:US
Mailing Address - Phone:910-471-0111
Mailing Address - Fax:
Practice Address - Street 1:10131 HIGHWAY 53 W
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425
Practice Address - Country:US
Practice Address - Phone:910-471-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist