Healthcare Provider Details

I. General information

NPI: 1366016636
Provider Name (Legal Business Name): ALYSSA MARIE WOJTALEWICZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date: 06/14/2021
Reactivation Date: 07/22/2021

III. Provider practice location address

1405 HERITAGE DR
SAINT PAUL NE
68873-3618
US

IV. Provider business mailing address

1189 JANSEN RD
SAINT PAUL NE
68873-6843
US

V. Phone/Fax

Practice location:
  • Phone: 308-754-5486
  • Fax:
Mailing address:
  • Phone: 402-990-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1127
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: