Provider Demographics
NPI:1619497716
Name:VANNATTA, ALEXANDRA GLOFF (LPC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:GLOFF
Last Name:VANNATTA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76638-3218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:719 JEWELL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6624
Practice Address - Country:US
Practice Address - Phone:254-870-1752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37048235Z00000X
TX84568101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39048OtherSTATE BOARD OF EXAMINERS FOR SPEECH PATHOLOGY