Provider Demographics
NPI:1972185346
Name:PETTY, ALYSSA NICOLE (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:NICOLE
Last Name:PETTY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W OXFORD PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1024
Mailing Address - Country:US
Mailing Address - Phone:502-287-2661
Mailing Address - Fax:
Practice Address - Street 1:3 W OXFORD PL
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1024
Practice Address - Country:US
Practice Address - Phone:502-287-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist