Healthcare Provider Details

I. General information

NPI: 1316679707
Provider Name (Legal Business Name): ALEXANDRA L DEYOUNG OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2022
Last Update Date: 06/26/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5960 BREWSTER DR
HUDSON OH
44236-3912
US

IV. Provider business mailing address

5960 BREWSTER DR
HUDSON OH
44236-3912
US

V. Phone/Fax

Practice location:
  • Phone: 330-592-5292
  • Fax:
Mailing address:
  • Phone: 330-592-5292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT012002
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: