=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174245310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISSA DIANE ALEXANDER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2022
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1161 E CLARK RD STE 360
-----------------------------------------------------
City | DEWITT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48820-7930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-507-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 S DIAMOND RD
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48854-9636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------