Provider Demographics
NPI:1134773674
Name:CONWAY, ALEXANDRA BLAIR (PHD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:BLAIR
Last Name:CONWAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SOUTHFIELD AVENUE APT 420
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:631-513-2981
Mailing Address - Fax:
Practice Address - Street 1:55 HOLLY HILL LANE SUITE 170
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-863-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003862103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008091020Medicaid