Provider Demographics
NPI:1154094290
Name:WAITES, ALEXANDER (LPC-IT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:WAITES
Suffix:
Gender:M
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 S 76TH ST STE 305
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4364
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:
Practice Address - Street 1:4811 S 76TH ST # 305
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:414-325-7741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5032-226101Y00000X
WI10314-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor