Provider Demographics
NPI:1811688682
Name:KNUTSON, ALEXIS ROSE (LLMSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ROSE
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:ROSE
Other - Last Name:DEROSHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:798 W 120TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:MI
Mailing Address - Zip Code:49327-9157
Mailing Address - Country:US
Mailing Address - Phone:616-710-6739
Mailing Address - Fax:
Practice Address - Street 1:1035 E JAMES ST
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-8744
Practice Address - Country:US
Practice Address - Phone:231-689-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851116328104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker