Provider Demographics
NPI:1720786718
Name:SMITH, ALEXIS KEANNA
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:KEANNA
Last Name:SMITH
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 1:14 OTTAWA AVE # A
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-9037
Mailing Address - Country:US
Mailing Address - Phone:740-501-0237
Mailing Address - Fax:
Practice Address - Street 1:1033 LARCHWOOD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2424
Practice Address - Country:US
Practice Address - Phone:419-747-4122
Practice Address - Fax:419-747-4126
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician