=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588049506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA WALLACE M.S. SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 04/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2350 ROUTE 63
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14572-9509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-765-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8864 WARNER RD
-----------------------------------------------------
City | WAYLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14572-9387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-765-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 024855
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------