Healthcare Provider Details

I. General information

NPI: 1194173989
Provider Name (Legal Business Name): ALEXANDRA KATHLEEN WELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

IV. Provider business mailing address

854 JOSLIN ST SE
GRAND RAPIDS MI
49507-3308
US

V. Phone/Fax

Practice location:
  • Phone: 616-826-4991
  • Fax:
Mailing address:
  • Phone: 616-280-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401000254
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: