Provider Demographics
NPI:1619360336
Name:EASTLAND, ALYSSA MARIE (PTA)
Entity Type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:MARIE
Last Name:EASTLAND
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33451 BRUSHY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6404
Mailing Address - Country:US
Mailing Address - Phone:714-916-7482
Mailing Address - Fax:
Practice Address - Street 1:24551 RAYMOND WAY
Practice Address - Street 2:SUITE 125
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4400
Practice Address - Country:US
Practice Address - Phone:949-540-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10787225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant