Provider Demographics
NPI:1982228557
Name:PETTY, ALYSSA (MA60430594)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:MA60430594
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S TOBIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5338
Mailing Address - Country:US
Mailing Address - Phone:425-243-7705
Mailing Address - Fax:425-321-5508
Practice Address - Street 1:200 S TOBIN ST STE A
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5338
Practice Address - Country:US
Practice Address - Phone:425-243-7705
Practice Address - Fax:425-321-5508
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60430594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist