Healthcare Provider Details

I. General information

NPI: 1184463119
Provider Name (Legal Business Name): ALEXANDRA YEWCIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 AMERICAN LEGION BLVD
MOUNTAIN HOME ID
83647-2821
US

IV. Provider business mailing address

2867 SE HUMMINGBIRD DR
MT HOME ID
83647-6019
US

V. Phone/Fax

Practice location:
  • Phone: 208-580-5431
  • Fax:
Mailing address:
  • Phone: 440-708-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: