Provider Demographics
NPI:1619264843
Name:LUTTRELL-BROWN, ALEXIS
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:
Last Name:LUTTRELL-BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:LUTTRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:625 DELAWARE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-1007
Mailing Address - Country:US
Mailing Address - Phone:716-882-3151
Mailing Address - Fax:
Practice Address - Street 1:2128 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1910
Practice Address - Country:US
Practice Address - Phone:716-874-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NY085068-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01465154Medicaid