Provider Demographics
NPI:1164858288
Name:BELLACK, ALEXIS THEONI (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:THEONI
Last Name:BELLACK
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 NEW BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2810
Mailing Address - Country:US
Mailing Address - Phone:307-631-0052
Mailing Address - Fax:
Practice Address - Street 1:5801 YELLOWSTONE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4174
Practice Address - Country:US
Practice Address - Phone:307-638-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-538235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist