=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154255412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEC GREGORY JAMES WIXSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2026
-----------------------------------------------------
Last Update Date | 06/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37367 6 MILE RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-402-2335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37367 6 MILE RD
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-402-2335
-----------------------------------------------------
Fax | 734-402-2338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 5502009080
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------