Healthcare Provider Details

I. General information

NPI: 1053635672
Provider Name (Legal Business Name): ALEXIS LEANN HANICQ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 N WILLIAMS ST
PAULDING OH
45879-1064
US

IV. Provider business mailing address

9844 US ROUTE 224
VAN WERT OH
45891-9110
US

V. Phone/Fax

Practice location:
  • Phone: 419-399-4711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA004375
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: