Provider Demographics
NPI:1184124901
Name:HINNEBUSCH, ALEXANDER JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:JOSEPH
Last Name:HINNEBUSCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4758 LYNNVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8990
Mailing Address - Country:US
Mailing Address - Phone:240-274-0012
Mailing Address - Fax:
Practice Address - Street 1:4758 LYNNVILLE WAY
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-8990
Practice Address - Country:US
Practice Address - Phone:240-274-0012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.07748103G00000X, 103T00000X
MI6301016833390200000X
NY025389-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program