Provider Demographics
NPI:1861275810
Name:DIAZ, ALYSSA NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NICOLE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ESTANCIA PKWY APT 336
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-2446
Mailing Address - Country:US
Mailing Address - Phone:254-258-9272
Mailing Address - Fax:
Practice Address - Street 1:5401 LA CROSSE AVE STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78739-2160
Practice Address - Country:US
Practice Address - Phone:512-852-8134
Practice Address - Fax:512-852-8143
Is Sole Proprietor?:No
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2178755225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant