Provider Demographics
NPI:1073128260
Name:WIIST, ALEXANDRA (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:WIIST
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-9626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-9626
Practice Address - Country:US
Practice Address - Phone:269-467-9575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151013433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist