Healthcare Provider Details

I. General information

NPI: 1154094290
Provider Name (Legal Business Name): ALEXANDER WAITES LPC-IT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 S 76TH ST # 305
GREENFIELD WI
53220-4364
US

IV. Provider business mailing address

4811 S 76TH ST STE 305
GREENFIELD WI
53220-4364
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7741
  • Fax:
Mailing address:
  • Phone: 414-325-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5032-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10314-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: