Provider Demographics
NPI:1275177131
Name:ALEXIS, BIANCA C
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:C
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 1:169 VAUXHALL ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-3821
Mailing Address - Country:US
Mailing Address - Phone:860-460-3520
Mailing Address - Fax:
Practice Address - Street 1:80 ERDMAN WAY # 208
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1840
Practice Address - Country:US
Practice Address - Phone:978-870-1840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health