Provider Demographics
NPI:1689128365
Name:GLOUDEMANS, ALYSSA ANNE (PT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANNE
Last Name:GLOUDEMANS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 LUPINE CT
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-8917
Mailing Address - Country:US
Mailing Address - Phone:920-810-4737
Mailing Address - Fax:
Practice Address - Street 1:500 S OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7944
Practice Address - Country:US
Practice Address - Phone:920-738-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13586-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist