Healthcare Provider Details

I. General information

NPI: 1417686205
Provider Name (Legal Business Name): ALYSSA LARSON DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA COONROD DPT

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 GOLF COURSE RD SE
RIO RANCHO NM
87124-1656
US

IV. Provider business mailing address

7849 TRAMWAY BLVD NE STE A
ALBUQUERQUE NM
87122-2529
US

V. Phone/Fax

Practice location:
  • Phone: 505-898-9700
  • Fax: 505-212-6991
Mailing address:
  • Phone: 505-821-3831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: