Provider Demographics
NPI:1285520536
Name:SHIRLEY, ALYSSA (OTR/L)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12222 W BRIDGER BAY DR
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5081
Mailing Address - Country:US
Mailing Address - Phone:208-473-1098
Mailing Address - Fax:
Practice Address - Street 1:12222 W BRIDGER BAY DR
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5081
Practice Address - Country:US
Practice Address - Phone:208-391-2773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-14
Last Update Date:2025-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6471866225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist