Provider Demographics
NPI:1174817530
Name:WUNDERLICH, ALEXIS NICOLE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:NICOLE
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:NICOLE
Other - Last Name:BIANCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:437 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2037
Mailing Address - Country:US
Mailing Address - Phone:724-344-0654
Mailing Address - Fax:
Practice Address - Street 1:130 KAUFMAN DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-363-5634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1544225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist