Healthcare Provider Details

I. General information

NPI: 1366082471
Provider Name (Legal Business Name): SHANISE MARIE ALEXANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 10TH ST APT A
LAS VEGAS NV
89101-7044
US

IV. Provider business mailing address

510 S 10TH ST APT A
LAS VEGAS NV
89101-7044
US

V. Phone/Fax

Practice location:
  • Phone: 702-462-6630
  • Fax: 702-462-6634
Mailing address:
  • Phone: 702-462-6630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: