Provider Demographics
NPI:1619420015
Name:RODAK, ALYSSA R (DPT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:R
Last Name:RODAK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:R
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 87294
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7294
Mailing Address - Country:US
Mailing Address - Phone:910-483-8331
Mailing Address - Fax:910-483-8335
Practice Address - Street 1:1289 OLIVER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4450
Practice Address - Country:US
Practice Address - Phone:910-483-8331
Practice Address - Fax:910-483-8335
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00142612251P0200X
NCCP-CP027853T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO19270429Medicaid