Healthcare Provider Details

I. General information

NPI: 1346779758
Provider Name (Legal Business Name): ALIX CHARLOTTE LANCASTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4139 ARBOLES BONITOS
SANTA FE NM
87507-1007
US

IV. Provider business mailing address

4139 ARBOLES BONITOS
SANTA FE NM
87507-1007
US

V. Phone/Fax

Practice location:
  • Phone: 323-493-0517
  • Fax: 323-493-0517
Mailing address:
  • Phone: 323-493-0517
  • Fax: 323-493-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-57361
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: