Healthcare Provider Details

I. General information

NPI: 1174234751
Provider Name (Legal Business Name): ALEXA ANN ANTONOPOULOS OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2543 TALISKER AVE
HENDERSON NV
89044-1715
US

IV. Provider business mailing address

2543 TALISKER AVE
HENDERSON NV
89044-1715
US

V. Phone/Fax

Practice location:
  • Phone: 440-522-7002
  • Fax:
Mailing address:
  • Phone: 440-522-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XG0600X
TaxonomyGerontology Occupational Therapist
License NumberOT-3122
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: