Provider Demographics
NPI:1518632520
Name:SHOCK, ALEXIS (STUDENT)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:SHOCK
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5073 W ELM CT
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-0606
Mailing Address - Country:US
Mailing Address - Phone:701-367-4585
Mailing Address - Fax:
Practice Address - Street 1:401 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1835
Practice Address - Country:US
Practice Address - Phone:218-779-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional