Provider Demographics
NPI:1942741251
Name:ALEXANDER, DEMITRA
Entity Type:Individual
Prefix:
First Name:DEMITRA
Middle Name:
Last Name:ALEXANDER
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:PO BOX 16046
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40256-0046
Mailing Address - Country:US
Mailing Address - Phone:502-424-5720
Mailing Address - Fax:
Practice Address - Street 1:2221 BUECHEL AVE BLDG 3
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2658
Practice Address - Country:US
Practice Address - Phone:502-442-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X, 261QM0850X, 172A00000X, 225600000X, 373H00000X
KY385HR2060X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No172A00000XOther Service ProvidersDriver
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist