Provider Demographics
NPI:1649892019
Name:BARTOLUCCI, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:BARTOLUCCI
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 1:282 S CANYON PARK RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61085-9025
Mailing Address - Country:US
Mailing Address - Phone:815-990-6161
Mailing Address - Fax:
Practice Address - Street 1:150 CARING WAY
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3455
Practice Address - Country:US
Practice Address - Phone:307-332-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
WI5338-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist