Provider Demographics
NPI:1720569932
Name:DAZA, ALYSSA LYNN (OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LYNN
Last Name:DAZA
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 1:7045 CHARMANT DR APT 164
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-4373
Mailing Address - Country:US
Mailing Address - Phone:516-316-5106
Mailing Address - Fax:
Practice Address - Street 1:8515 COSTA VERDE BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-1130
Practice Address - Country:US
Practice Address - Phone:888-674-4036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT18211225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation