Healthcare Provider Details

I. General information

NPI: 1679659221
Provider Name (Legal Business Name): ALYSSA CATHERINE LAFORME FISS PT, PHD, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 COOPERS GLEN DR SW
MABLETON GA
30126-2584
US

IV. Provider business mailing address

22 COOPERS GLEN DR SW
MABLETON GA
30126-2584
US

V. Phone/Fax

Practice location:
  • Phone: 859-221-4509
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-004517
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT009001
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: