Healthcare Provider Details

I. General information

NPI: 1669187647
Provider Name (Legal Business Name): ALISA MARIA WINCHESTER DE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17320 W 12 MILE RD
SOUTHFIELD MI
48076-2100
US

IV. Provider business mailing address

6850 RICHMOND HWY APT 636
ALEXANDRIA VA
22306-1775
US

V. Phone/Fax

Practice location:
  • Phone: 248-727-3456
  • Fax: 248-557-4697
Mailing address:
  • Phone: 302-507-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberQ3-0011593
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: