Provider Demographics
NPI:1912205246
Name:ANNIS, ALEXANDER N (EDS, MED)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:N
Last Name:ANNIS
Suffix:
Gender:M
Credentials:EDS, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 FOREST VIEW LN
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3493
Mailing Address - Country:US
Mailing Address - Phone:262-468-8990
Mailing Address - Fax:
Practice Address - Street 1:405 E FOREST ST
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3707
Practice Address - Country:US
Practice Address - Phone:262-468-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-10
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006974101YM0800X
NC8283101YM0800X
WI8460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health