Provider Demographics
NPI:1760957559
Name:MACKIN, ALEXIS NICOLE GROCE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE GROCE
Last Name:MACKIN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:NICOLE
Other - Last Name:GROCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2015 SANDBOX RD
Mailing Address - Street 2:
Mailing Address - City:HARRINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19952-2666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2015 SANDBOX RD
Practice Address - Street 2:
Practice Address - City:HARRINGTON
Practice Address - State:DE
Practice Address - Zip Code:19952-2666
Practice Address - Country:US
Practice Address - Phone:302-535-3164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0001958225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEU1-0001958OtherSTATE OF DELAWARE