Provider Demographics
NPI:1922429539
Name:RICHARDSON, ALLYSSA (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ALLYSSA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4026 SOUTHERN OAKS DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0972
Mailing Address - Country:US
Mailing Address - Phone:757-880-7195
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ROAD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260017892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer