Provider Demographics
NPI:1629783550
Name:REAGAN, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:REAGAN
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 1:1194 SER J DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:27525-9750
Mailing Address - Country:US
Mailing Address - Phone:907-602-7313
Mailing Address - Fax:
Practice Address - Street 1:110 CAPCOM AVE STE 101
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6531
Practice Address - Country:US
Practice Address - Phone:919-907-3687
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician