Provider Demographics
NPI:1275099079
Name:ALSTON, XAVIER
Entity Type:Individual
Prefix:
First Name:XAVIER
Middle Name:
Last Name:ALSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8527 FRANKLIN COVE WAY APT G
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-2262
Mailing Address - Country:US
Mailing Address - Phone:317-746-4971
Mailing Address - Fax:
Practice Address - Street 1:8527 FRANKLIN COVE WAY APT G
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-2262
Practice Address - Country:US
Practice Address - Phone:317-746-4971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-17
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1114498136Medicaid