Provider Demographics
NPI:1144891490
Name:PODSKALAN, ALYSSA RENEE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:RENEE
Last Name:PODSKALAN
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 1:5970 AVALON DR APT 226
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-7764
Mailing Address - Country:US
Mailing Address - Phone:913-775-3606
Mailing Address - Fax:
Practice Address - Street 1:5970 AVALON DR APT 226
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-7764
Practice Address - Country:US
Practice Address - Phone:913-775-3606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68925225800000X
MI1-24-72802103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist