Provider Demographics
NPI:1689240590
Name:AHLSTROM, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:AHLSTROM
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 1:24402 W LOCKPORT ST STE 124
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-4288
Mailing Address - Country:US
Mailing Address - Phone:815-239-0395
Mailing Address - Fax:815-239-0408
Practice Address - Street 1:24402 W LOCKPORT ST STE 124
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-4288
Practice Address - Country:US
Practice Address - Phone:815-239-0395
Practice Address - Fax:815-239-0408
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician