Provider Demographics
NPI:1902429061
Name:NEWSOME, ALYSSA (MA, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:NEWSOME
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25845 TECLA AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-4113
Mailing Address - Country:US
Mailing Address - Phone:586-484-8263
Mailing Address - Fax:
Practice Address - Street 1:51145 NICOLETTE DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-4585
Practice Address - Country:US
Practice Address - Phone:586-228-9991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7401001104103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1-20-41662OtherBEHAVIOR ANALYST CERTIFICATION BOARD