Provider Demographics
NPI:1770068116
Name:COLVIN, ALYSSA CONSTANCE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CONSTANCE
Last Name:COLVIN
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 1:2 ELMWOOD AVE APT 31
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-1872
Mailing Address - Country:US
Mailing Address - Phone:803-257-3332
Mailing Address - Fax:
Practice Address - Street 1:22 PLEASANT ST # 2000
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5119
Practice Address - Country:US
Practice Address - Phone:781-851-2648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12745104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker