Healthcare Provider Details

I. General information

NPI: 1801720800
Provider Name (Legal Business Name): ALYSSA NOEL BRANDON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STATE ROUTE 664 N
LOGAN OH
43138-8541
US

IV. Provider business mailing address

13468 PLEASANT VALLEY RD
ROCKBRIDGE OH
43149-9769
US

V. Phone/Fax

Practice location:
  • Phone: 740-380-8284
  • Fax:
Mailing address:
  • Phone: 740-279-9079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number09723
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: