Healthcare Provider Details

I. General information

NPI: 1811688682
Provider Name (Legal Business Name): ALEXIS ROSE KNUTSON LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXIS ROSE DEROSHA

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 E JAMES ST
WHITE CLOUD MI
49349-8744
US

IV. Provider business mailing address

798 W 120TH ST
GRANT MI
49327-9157
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7330
  • Fax:
Mailing address:
  • Phone: 616-710-6739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851116328
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: