Provider Demographics
NPI:1629805155
Name:SHAFT, ALYSSA MARIE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MARIE
Last Name:SHAFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12438 67TH CT NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330-6705
Mailing Address - Country:US
Mailing Address - Phone:612-364-4555
Mailing Address - Fax:
Practice Address - Street 1:3401 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-3315
Practice Address - Country:US
Practice Address - Phone:612-509-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician