Provider Demographics
NPI:1184064743
Name:ORTON, ALYSSA ANN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ANN
Last Name:ORTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 E ELLER DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-5418
Mailing Address - Country:US
Mailing Address - Phone:309-269-6120
Mailing Address - Fax:
Practice Address - Street 1:PEORIA DEVELOPMENTAL CENTER
Practice Address - Street 2:2018 W CIMARRON DRIVE
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6161
Practice Address - Country:US
Practice Address - Phone:309-693-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005711A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146011140OtherILLINOIS SPEECH LANGUAGE PATHOLOGIST LICENSE