Healthcare Provider Details

I. General information

NPI: 1205420874
Provider Name (Legal Business Name): ALYSSA KAYLEE PELLMANN PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 UNITED DR STE 100
COLLINSVILLE IL
62234-7428
US

IV. Provider business mailing address

215 WHEAT RIDGE LN
MILLSTADT IL
62260-1259
US

V. Phone/Fax

Practice location:
  • Phone: 618-343-1122
  • Fax: 618-343-1444
Mailing address:
  • Phone: 618-795-8184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2021006238
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: