Provider Demographics
NPI:1811461577
Name:SCOVILLE, ALYSSA JANE (DPT)
Entity type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:JANE
Last Name:SCOVILLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:JANE
Other - Last Name:SURGENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8912 MORITZ AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1733
Mailing Address - Country:US
Mailing Address - Phone:314-607-0068
Mailing Address - Fax:
Practice Address - Street 1:12380 DE PAUL DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2511
Practice Address - Country:US
Practice Address - Phone:314-447-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018039733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist