Provider Demographics
NPI:1962911230
Name:OTTEN, ALYSSA NICOLE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:OTTEN
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 1:17160 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:NUNICA
Mailing Address - State:MI
Mailing Address - Zip Code:49448-9450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17160 130TH AVE
Practice Address - Street 2:
Practice Address - City:NUNICA
Practice Address - State:MI
Practice Address - Zip Code:49448-9450
Practice Address - Country:US
Practice Address - Phone:616-847-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101Y00000X, 171M00000X
MI6803087239104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator