=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073318549
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS MARIE HASSAN THOMAS BS, SAC-IT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2025
-----------------------------------------------------
Last Update Date | 02/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3707 N RICHARDS ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53212-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-967-7006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3240 MARKET LN APT 4021
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53144-3477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-287-3757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 20771130
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 20771130
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------