Provider Demographics
NPI:1861035321
Name:FOSMIRE, ALISA DOMINIQUE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:DOMINIQUE
Last Name:FOSMIRE
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 1:8848 MIDLAKE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13030-9726
Mailing Address - Country:US
Mailing Address - Phone:520-309-5946
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-2302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024168225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist