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General NPI Number Information
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NPI Number | 1811536063
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Entity Type | Individual
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Provider Name | ALYSA MAE CLOUSE
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Gender | Female
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Dates
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Enumeration Date | 01/04/2020
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Last Update Date | 10/11/2022
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Provider Practice Location Address
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Address Line | 120 STEVENS ST SW
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City | GRAND RAPIDS
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State | MI
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Zip | 49507-1526
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Country | US
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Telephone | 734-799-2402
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Fax |
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Provider Business Mailing Address
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Address Line | 5917 ELMWOOD ST
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City | MONROE
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State | MI
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Zip | 48161-3958
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Country | US
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Telephone | 734-799-2402
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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