Provider Demographics
NPI:1659917896
Name:SUSSMAN, ALYSHA JACELYN
Entity Type:Individual
Prefix:
First Name:ALYSHA
Middle Name:JACELYN
Last Name:SUSSMAN
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 1:4410 6TH AVE SE UNIT 403
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1058
Mailing Address - Country:US
Mailing Address - Phone:503-998-5328
Mailing Address - Fax:
Practice Address - Street 1:3436 MARY ELDER RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5050
Practice Address - Country:US
Practice Address - Phone:360-528-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health