Provider Demographics
NPI:1639870876
Name:NIEDRAUER, ALEX DAVID
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:DAVID
Last Name:NIEDRAUER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S M ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6620
Mailing Address - Country:US
Mailing Address - Phone:805-736-0357
Mailing Address - Fax:866-543-5841
Practice Address - Street 1:113 S M ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6620
Practice Address - Country:US
Practice Address - Phone:805-736-0357
Practice Address - Fax:866-543-5841
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14895101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)