Provider Demographics
NPI:1912520255
Name:SPEAKE, ALYSSA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:SPEAKE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SEVEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-6034
Mailing Address - Country:US
Mailing Address - Phone:678-787-4669
Mailing Address - Fax:
Practice Address - Street 1:204 SHADY PINES CT
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-9785
Practice Address - Country:US
Practice Address - Phone:864-399-9785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5830225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist