Basic Information
| Provider Information | |||||||||
| NPI: | 1245303015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUBBERT | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | LEANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1009 DOLAN DR | ||||||||
| Address2: | |||||||||
| City: | GRIMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501111028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157783926 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 NE DARTMOOR DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAUKEE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159876267 | ||||||||
| FaxNumber: | 5159876269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 02888 | IA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | (0) 449579 | 05 | IA | MEDICAID |