Provider Demographics
NPI:1679854194
Name:WILKERSON MAIXNER, RAE ALEXANDRA (PHD)
Entity Type:Individual
Prefix:MRS
First Name:RAE
Middle Name:ALEXANDRA
Last Name:WILKERSON MAIXNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:MAIXNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PL STE 3N-14
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6069
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PL STE 3N-14
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2017033399103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program