Provider Demographics
NPI:1184972267
Name:FETTERS, ALYSSA LORELLE (MA, OTR/L)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:LORELLE
Last Name:FETTERS
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 HARVARD PL
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4734
Mailing Address - Country:US
Mailing Address - Phone:951-990-1720
Mailing Address - Fax:
Practice Address - Street 1:115 HARVARD PL
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4734
Practice Address - Country:US
Practice Address - Phone:951-990-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11554225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics