Provider Demographics
NPI:1427109289
Name:ALYSSON, TRACEY LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:LEE
Last Name:ALYSSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-6130
Mailing Address - Country:US
Mailing Address - Phone:603-313-2517
Mailing Address - Fax:
Practice Address - Street 1:2937 ROUTE 611
Practice Address - Street 2:
Practice Address - City:TANNERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18372-9990
Practice Address - Country:US
Practice Address - Phone:570-269-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH260103TC0700X
PAPS017890103TC0700X
MA3193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0602230YONHOIOtherANTHEM
NH0602230YONHOIOtherANTHEM
NH0602230YONHOIOtherANTHEM