Healthcare Provider Details

I. General information

NPI: 1386161883
Provider Name (Legal Business Name): ALEXANDER IVORY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6639 CENTURION DR STE 130
LANSING MI
48917-8273
US

IV. Provider business mailing address

23077 GREENFIELD RD., STE. 455 PMB 1031
SOUTHFIELD MI
48075
US

V. Phone/Fax

Practice location:
  • Phone: 517-322-3050
  • Fax:
Mailing address:
  • Phone: 248-973-7646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451022758
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: