Provider Demographics
NPI:1710556212
Name:OLIVERSEN, ALYSSA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:OLIVERSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 GOODRICH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2727
Mailing Address - Country:US
Mailing Address - Phone:507-460-9498
Mailing Address - Fax:
Practice Address - Street 1:2155 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-2799
Practice Address - Country:US
Practice Address - Phone:615-696-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12238225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist