MEDICARE: MRS. ALEXIS VICHNIAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist	442207 7335	MA

General Provider Information

NPI Number	:	1982987020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALEXIS VICHNIAC

Provider Business Mailing Address
First Line	:	163 ELM ST
Second Line	:	3
City	:	SOMERVILLE
State	:	MA
Zip	:	02144-3110
Country	:	US
Telephone Number	:	617-571-8058
Fax Number	:

Provider Business Practice Location Address
First Line	:	163 ELM ST
Second Line	:	3
City	:	SOMERVILLE
State	:	MA
Zip	:	02144-3110
Country	:	US
Telephone Number	:	617-571-8058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2011
Last Update Date	:	09/26/2011

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