Provider Demographics
NPI:1811776784
Name:ALLEN, ALYSSA E
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:E
Last Name:ALLEN
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 1:212 TUDOR CIR APT 121
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1394
Mailing Address - Country:US
Mailing Address - Phone:269-436-0702
Mailing Address - Fax:
Practice Address - Street 1:115 W ALLEGAN ST
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MI
Practice Address - Zip Code:49078-1115
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician