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General NPI Number Information
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NPI Number | 1376810887
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Entity Type | Individual
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Provider Name | ALYSSA MCPHERSON LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 11/29/2011
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Last Update Date | 11/29/2011
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Provider Practice Location Address
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Address Line | 101 N. JORDAN AVE. MUSICAL ARTS CENTER: ROOM 401
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City | BLOOMINGTON
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State | IN
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Zip | 47406
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Country | US
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Telephone | 317-696-1204
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Fax |
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Provider Business Mailing Address
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Address Line | 2611 N. WALNUT ST., APT. 9
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City | BLOOMINGTON
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State | IN
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Zip | 47404
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Country | US
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Telephone | 317-696-1204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36001859A
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License Number State | IN
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