Healthcare Provider Details

I. General information

NPI: 1770137556
Provider Name (Legal Business Name): ALEC VICENZI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 WHITEWATER DR STE 101
MINNETONKA MN
55343-4157
US

IV. Provider business mailing address

1933 RANDOLPH AVE
SAINT PAUL MN
55105-1746
US

V. Phone/Fax

Practice location:
  • Phone: 952-999-6097
  • Fax:
Mailing address:
  • Phone: 608-208-3065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: