Healthcare Provider Details

I. General information

NPI: 1922774090
Provider Name (Legal Business Name): ALEXANDRA LAUREN DIVINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2021
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FERREL ST
PLATTE CITY MO
64079-9511
US

IV. Provider business mailing address

214 FERREL ST
PLATTE CITY MO
64079-9511
US

V. Phone/Fax

Practice location:
  • Phone: 816-469-5162
  • Fax:
Mailing address:
  • Phone: 816-469-5162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: