MEDICARE: ALISSA STAUFFER

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1679103568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA STAUFFER

Provider Business Mailing Address
First Line	:	4 SONORA DR
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-2114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1211 FARMINGTON LAKES DR
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-5109
Country	:	US
Telephone Number	:	630-509-4166
Fax Number	:

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

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	12/14/2022

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