Provider Demographics
NPI:1649378829
Name:DEGENHARDT, ALEXANDRA L
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:L
Last Name:DEGENHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GLEN COVE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4235
Mailing Address - Country:US
Mailing Address - Phone:207-593-5757
Mailing Address - Fax:207-593-5357
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-593-5757
Practice Address - Fax:207-593-5357
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2413092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH90967Medicare UPIN