Provider Demographics
NPI:1063043875
Name:MODELL, ALEXANDRA (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MODELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 N IRONWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5225 N IRONWOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4909
Practice Address - Country:US
Practice Address - Phone:414-491-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI948-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNEITHER MEDICARE OR MEDICAID, AS ACUPUNCTURE IS NOT COVERED
NONEOtherACUPUNCTURE IS NOT COVERED CURRENTLY UNDER MEDICARE AND MEDICADE