Healthcare Provider Details

I. General information

NPI: 1023628971
Provider Name (Legal Business Name): ALEXANDRA WURST M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 11/27/2023
Certification Date: 08/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 S MAIN ST UNIT 3221
GRAPEVINE TX
76051-7558
US

IV. Provider business mailing address

925 S MAIN ST UNIT 3221
GRAPEVINE TX
76051-7558
US

V. Phone/Fax

Practice location:
  • Phone: 314-322-0514
  • Fax:
Mailing address:
  • Phone: 214-587-8751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number113844
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: