Provider Demographics
NPI:1134675754
Name:WICKE, ALEXIS (MA, BCBA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:WICKE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 E 12TH ST STE C2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4672
Mailing Address - Country:US
Mailing Address - Phone:248-846-8700
Mailing Address - Fax:
Practice Address - Street 1:2111 GOLFSIDE RD STE 3
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1145
Practice Address - Country:US
Practice Address - Phone:248-846-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI7401000906103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other