=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447060801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA TALBERT DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2025
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1355 W WHITE MOUNTAIN BLVD STE B
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-7068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-537-2678
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 GOOSELEG WAY
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-6595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-531-5315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | LPT-034021
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------