Provider Demographics
NPI:1740762376
Name:DEFINA, ALEXANDRA ADELE (LICSW)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:ADELE
Last Name:DEFINA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-412-3112
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-412-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW035991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical