Provider Demographics
NPI:1285002857
Name:FORTSON, ALEXIS DANIELLE
Entity Type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:DANIELLE
Last Name:FORTSON
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 1:1123 BETTY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-3928
Mailing Address - Country:US
Mailing Address - Phone:706-326-1982
Mailing Address - Fax:
Practice Address - Street 1:300 COLONIAL CENTER PKWY STE NROSWELL
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4899
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-12
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist