Provider Demographics
NPI:1710231725
Name:GRISTWOOD, ALISSA LEA (TSHH)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:LEA
Last Name:GRISTWOOD
Suffix:
Gender:F
Credentials:TSHH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 PINNACLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-4355
Mailing Address - Country:US
Mailing Address - Phone:315-806-8166
Mailing Address - Fax:
Practice Address - Street 1:153 PINNACLE HILL RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-4355
Practice Address - Country:US
Practice Address - Phone:315-806-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12567642355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant