Provider Demographics
NPI:1437703170
Name:ITSKOVICH, ALEXIS N (SLP-CF)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:N
Last Name:ITSKOVICH
Suffix:
Gender:F
Credentials:SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6855 LEYTONSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1243
Mailing Address - Country:US
Mailing Address - Phone:248-872-2588
Mailing Address - Fax:
Practice Address - Street 1:41150 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5088
Practice Address - Country:US
Practice Address - Phone:248-955-4956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist