Provider Demographics
NPI:1134808504
Name:DETTMAN, ALEXA GABRIELLE
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:GABRIELLE
Last Name:DETTMAN
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 1:13272 HARBORVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8414
Mailing Address - Country:US
Mailing Address - Phone:989-277-0641
Mailing Address - Fax:
Practice Address - Street 1:1402 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3705
Practice Address - Country:US
Practice Address - Phone:810-424-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician