Provider Demographics
NPI:1922771997
Name:MUSGROVE, ALEXIS D
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:D
Last Name:MUSGROVE
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 1:238 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2925
Mailing Address - Country:US
Mailing Address - Phone:330-318-3436
Mailing Address - Fax:
Practice Address - Street 1:318 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-4605
Practice Address - Country:US
Practice Address - Phone:330-395-9563
Practice Address - Fax:330-393-5975
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 172V00000X
OHC.2203763-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker