Provider Demographics
NPI:1841657418
Name:CARL, ALYSSA (LCSW)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:CARL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55934 TETON CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8795
Mailing Address - Country:US
Mailing Address - Phone:517-410-6093
Mailing Address - Fax:
Practice Address - Street 1:225 N NOTRE DAME AVE STE 5
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2836
Practice Address - Country:US
Practice Address - Phone:517-410-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
IN34007218A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1841657418Medicaid