Provider Demographics
NPI:1972249597
Name:ABBOTT, ALEXCIS
Entity Type:Individual
Prefix:
First Name:ALEXCIS
Middle Name:
Last Name:ABBOTT
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 1:202 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:IN
Mailing Address - Zip Code:47272
Mailing Address - Country:US
Mailing Address - Phone:317-512-0683
Mailing Address - Fax:
Practice Address - Street 1:202 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:IN
Practice Address - Zip Code:47272
Practice Address - Country:US
Practice Address - Phone:317-512-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LOA134038321001OtherBLUECROSS BLUESHIELD