Provider Demographics
NPI:1548697774
Name:WILSON, ALYSSA (PHD, BCBA-D)
Entity type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4497 PERSHING AVE APT 513
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2529
Mailing Address - Country:US
Mailing Address - Phone:775-721-7986
Mailing Address - Fax:
Practice Address - Street 1:232 BRUNS LANE
Practice Address - Street 2:ONE SPARCENTER PLAZA
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-793-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst