Healthcare Provider Details

I. General information

NPI: 1932655990
Provider Name (Legal Business Name): AYAMA PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 PIKE ST
LEMONT PA
16851
US

IV. Provider business mailing address

80 CORNFIELD LN
PORT MATILDA PA
16870-8335
US

V. Phone/Fax

Practice location:
  • Phone: 814-470-1868
  • Fax:
Mailing address:
  • Phone: 814-470-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016376
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS018048
License Number StatePA

VIII. Authorized Official

Name: DR. ALISSA S YAMASAKI
Title or Position: LICENSED PSYCHOLOGIST/OWNER
Credential: PH.D.
Phone: 814-470-1868