Provider Demographics
NPI:1700436953
Name:SOUTH, ALEXA (RBT)
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WISE ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:TX
Mailing Address - Zip Code:79510-4001
Mailing Address - Country:US
Mailing Address - Phone:325-232-1738
Mailing Address - Fax:
Practice Address - Street 1:4606 S 14TH ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-4735
Practice Address - Country:US
Practice Address - Phone:325-704-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19-98876106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19-98876OtherTRICARE