Provider Demographics
NPI:1356562177
Name:ALEXANDER, CLYDE (PHD, LMSW)
Entity type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:PHD, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4787 SHORELINE BLVD.
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329
Mailing Address - Country:US
Mailing Address - Phone:248-499-3655
Mailing Address - Fax:248-383-8081
Practice Address - Street 1:43996 WOODWARD AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-335-1711
Practice Address - Fax:248-335-7950
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010598151041C0700X, 104100000X, 103TB0200X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM37800002Medicare ID - Type Unspecified