Provider Demographics
NPI:1639963408
Name:ANDERSEN, ALYSSON
Entity type:Individual
Prefix:
First Name:ALYSSON
Middle Name:
Last Name:ANDERSEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16760 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8864
Mailing Address - Country:US
Mailing Address - Phone:616-317-2672
Mailing Address - Fax:
Practice Address - Street 1:16760 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-8864
Practice Address - Country:US
Practice Address - Phone:616-317-6272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician