Basic Information
| Provider Information | |||||||||
| NPI: | 1588137020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DITTMER | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | PT, DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 CORPORATE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640761135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166334063 | ||||||||
| FaxNumber: | 8162303230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2019 | ||||||||
| LastUpdateDate: | 08/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-07055 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 2022030328 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.