Healthcare Provider Details

I. General information

NPI: 1255818928
Provider Name (Legal Business Name): ALYSSA WALTERS MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA HAAS

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 DE PAUL DR
BRIDGETON MO
63044-2511
US

IV. Provider business mailing address

319 PAPILLON DR
BELLEVILLE IL
62226-1048
US

V. Phone/Fax

Practice location:
  • Phone: 314-447-9710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2018025618
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: