Provider Demographics
NPI:1578273918
Name:EUBANKS, ALYSSA J
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:J
Last Name:EUBANKS
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 1:29852 COUNTY ROAD 22
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-8611
Mailing Address - Country:US
Mailing Address - Phone:574-322-8569
Mailing Address - Fax:
Practice Address - Street 1:3524 MISHAWAKA AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-2424
Practice Address - Country:US
Practice Address - Phone:574-520-4326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty