Provider Demographics
NPI:1467068403
Name:LERTOLA, ALEXANDRA RAE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:RAE
Last Name:LERTOLA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53940 CARMICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1564
Mailing Address - Country:US
Mailing Address - Phone:574-335-6212
Mailing Address - Fax:574-335-0809
Practice Address - Street 1:53940 CARMICHAEL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1564
Practice Address - Country:US
Practice Address - Phone:574-335-6212
Practice Address - Fax:574-335-0809
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007598A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist