Provider Demographics
NPI:1518332584
Name:ALEXANDER, GRETA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:
Last Name:ALEXANDER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 WHITLEY TRAIL SUBD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40744-9440
Mailing Address - Country:US
Mailing Address - Phone:606-682-9579
Mailing Address - Fax:
Practice Address - Street 1:261 WHITLEY TRAIL SUBD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-9440
Practice Address - Country:US
Practice Address - Phone:606-682-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100385960Medicaid
KYK147701OtherMEDICARE