Healthcare Provider Details

I. General information

NPI: 1821622416
Provider Name (Legal Business Name): ALEXANDER ASA WILLMARTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31557 SCHOOLCRAFT ROAD SUITE 200 31557 SCHOOLCRAFT ROAD SUITE 200
LIVONIA MI
48150
US

IV. Provider business mailing address

31557 SCHOOLCRAFT ROAD SUITE 200 31557 SCHOOLCRAFT ROAD SUITE 200
LIVONIA MI
48150
US

V. Phone/Fax

Practice location:
  • Phone: 734-474-2958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002709
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: