Healthcare Provider Details

I. General information

NPI: 1134078009
Provider Name (Legal Business Name): ALEXIS NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2026
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17224 VAN WAGONER RD
SPRING LAKE MI
49456-9702
US

IV. Provider business mailing address

203 ALDEN ST
SPRING LAKE MI
49456-1762
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-2130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851120632
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: