Provider Demographics
NPI:1891285748
Name:FORMYDUVAL, ALYSSA ROSE MARIE (MS, OTR/L, CSRS)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:ROSE MARIE
Last Name:FORMYDUVAL
Suffix:
Gender:F
Credentials:MS, OTR/L, CSRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 FIR ST
Mailing Address - Street 2:
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3097
Mailing Address - Country:US
Mailing Address - Phone:219-392-7400
Mailing Address - Fax:
Practice Address - Street 1:4321 FIR ST
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3097
Practice Address - Country:US
Practice Address - Phone:219-392-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005709A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist