Provider Demographics
NPI:1598387227
Name:VANDERAH, ALYSSA MARIE
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:VANDERAH
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 1:851 W CORNELIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1723
Mailing Address - Country:US
Mailing Address - Phone:608-778-7263
Mailing Address - Fax:
Practice Address - Street 1:1806 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4938
Practice Address - Country:US
Practice Address - Phone:312-604-3740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant