Provider Demographics
NPI:1467853358
Name:SEBUKE, ALEXSANDER (COTA)
Entity Type:Individual
Prefix:
First Name:ALEXSANDER
Middle Name:
Last Name:SEBUKE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8172 DEEPWOOD BLVD
Mailing Address - Street 2:UNIT 11
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-9203
Mailing Address - Country:US
Mailing Address - Phone:440-525-0888
Mailing Address - Fax:
Practice Address - Street 1:8172 DEEPWOOD BLVD
Practice Address - Street 2:UNIT 11
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-9203
Practice Address - Country:US
Practice Address - Phone:440-525-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.05631224Z00000X
FLOTA13477224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant