Provider Demographics
NPI:1710601018
Name:BROCKMANN, ALYSSA NICOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:BROCKMANN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LITTLE BRIGGINS CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9723
Mailing Address - Country:US
Mailing Address - Phone:585-489-6166
Mailing Address - Fax:
Practice Address - Street 1:1057 E HENRIETTA RD STE 500
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2655
Practice Address - Country:US
Practice Address - Phone:927-758-5427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027215225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics