Healthcare Provider Details

I. General information

NPI: 1164073359
Provider Name (Legal Business Name): ALYSSA ZUCCALA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3782 HIGHWAY 95 STE 2
BULLHEAD CITY AZ
86442-8124
US

IV. Provider business mailing address

712 PLAZA GRANADA
LAKE HAVASU CITY AZ
86406-7727
US

V. Phone/Fax

Practice location:
  • Phone: 928-763-0807
  • Fax: 928-763-0827
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-013991
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: