Provider Demographics
NPI:1932682614
Name:AREVALO, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16201 ROUGH OAK ST APT 1313
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1854
Mailing Address - Country:US
Mailing Address - Phone:946-207-8696
Mailing Address - Fax:
Practice Address - Street 1:4211 GARDENDALE ST STE A201
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3180
Practice Address - Country:US
Practice Address - Phone:210-614-4434
Practice Address - Fax:210-614-4407
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37835251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37835OtherTX STATE BOARD OF SPEECH AND AUDIOLOGY