MEDICARE: ALEXA VISOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1976309	OTHER	MO	RBT

General Provider Information

NPI Number	:	1508426180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXA VISOR

Provider Business Mailing Address
First Line	:	9374 OLIVE BLVD STE 101
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-3253
Country	:	US
Telephone Number	:	314-665-1166
Fax Number	:

Provider Business Practice Location Address
First Line	:	7 E GREGORY BLVD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64114-1117
Country	:	US
Telephone Number	:	816-474-3995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2019
Last Update Date	:	06/17/2019

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