Provider Demographics
NPI:1083288294
Name:ALEXIS, MAUDRO
Entity Type:Individual
Prefix:
First Name:MAUDRO
Middle Name:
Last Name:ALEXIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2709
Mailing Address - Country:US
Mailing Address - Phone:347-300-4943
Mailing Address - Fax:
Practice Address - Street 1:18 MICROLAB RD STE 3
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-1640
Practice Address - Country:US
Practice Address - Phone:862-253-3109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician