Provider Demographics
NPI:1689954992
Name:BRENNAN, ALISSA MICHELE (PTA)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:MICHELE
Last Name:BRENNAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 E BROWN RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5470
Mailing Address - Country:US
Mailing Address - Phone:480-807-6644
Mailing Address - Fax:
Practice Address - Street 1:2835 E BROWN RD
Practice Address - Street 2:STE 101
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5470
Practice Address - Country:US
Practice Address - Phone:480-807-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0145A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant