MEDICARE: ALYSSA DOUGLASS ORT/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	225X00000X	Occupational Therapist	5201011419	MI

General Provider Information

NPI Number	:	1144715731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALYSSA DOUGLASS ORT/L

Provider Business Mailing Address
First Line	:	1617 E MILHAM AVE STE B
Second Line	:
City	:	PORTAGE
State	:	MI
Zip	:	49002-3049
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2510 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-8042
Country	:	US
Telephone Number	:	616-259-0408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	10/21/2021

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Directions to “ ALYSSA DOUGLASS ORT/L” Practice Location

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