Healthcare Provider Details

I. General information

NPI: 1356157549
Provider Name (Legal Business Name): ALEXIS THREAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 S INDEPENDENCE BLVD STE 1B
VIRGINIA BEACH VA
23453-4773
US

IV. Provider business mailing address

3864 BANYAN GROVE LN APT 206
VIRGINIA BEACH VA
23462-7491
US

V. Phone/Fax

Practice location:
  • Phone: 757-622-7272
  • Fax:
Mailing address:
  • Phone: 757-609-5416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: