Provider Demographics
NPI:1801352919
Name:JOHNSON, ALYSSA J
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:J
Other - Last Name:MANCHETER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1261 CENTRAL BELLE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-7617
Mailing Address - Country:US
Mailing Address - Phone:607-215-3402
Mailing Address - Fax:
Practice Address - Street 1:3023 NY-430
Practice Address - Street 2:
Practice Address - City:GREENHURST
Practice Address - State:NY
Practice Address - Zip Code:14742
Practice Address - Country:US
Practice Address - Phone:716-483-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010539225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant