Provider Demographics
NPI:1366093577
Name:MATTHEWS, ALYSSA ADELINE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ADELINE
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28200 SNIPE RD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65556-7455
Mailing Address - Country:US
Mailing Address - Phone:708-897-5438
Mailing Address - Fax:
Practice Address - Street 1:6330 NW KELLY DR STE A
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-4027
Practice Address - Country:US
Practice Address - Phone:816-569-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-28
Last Update Date:2019-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-87077106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician