MEDICARE: ALEXANDRA D STALEY MA, TLLP

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	103TS0200X	School Psychologist	SP0000001037014	MI

General Provider Information

NPI Number	:	1568390086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA D STALEY MA, TLLP

Provider Business Mailing Address
First Line	:	2425 TUXEDO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48206-1222
Country	:	US
Telephone Number	:	313-252-3070
Fax Number	:

Provider Business Practice Location Address
First Line	:	2425 TUXEDO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48206-1222
Country	:	US
Telephone Number	:	313-552-1257
Fax Number	:

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

Provider Enumeration Date	:	05/13/2026
Last Update Date	:	05/13/2026

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