Basic Information
| Provider Information | |||||||||
| NPI: | 1366174153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | ALYSE | ||||||||
| MiddleName: | ROSEANN | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9220 KIRBY DR STE 1000 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770542534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7133839700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1351 E BARDIN RD STE 160 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760182137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177951291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2022 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 217339 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.