Provider Demographics
NPI:1831679109
Name:MCKENNON, ALYSSA SHAY (COTA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:SHAY
Last Name:MCKENNON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:SANTO
Mailing Address - State:TX
Mailing Address - Zip Code:76472-2426
Mailing Address - Country:US
Mailing Address - Phone:940-329-8496
Mailing Address - Fax:
Practice Address - Street 1:1201 HOLLAND LAKE DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5851
Practice Address - Country:US
Practice Address - Phone:817-598-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215290224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant