Provider Demographics
NPI:1871995597
Name:GLICK, ALEXA (BCBA)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:
Last Name:GLICK
Suffix:
Gender:
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5532 BARRANCA OVERLOOK CT NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-2646
Mailing Address - Country:US
Mailing Address - Phone:630-862-4736
Mailing Address - Fax:
Practice Address - Street 1:277 E AMADOR AVE STE 101
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3675
Practice Address - Country:US
Practice Address - Phone:505-584-2634
Practice Address - Fax:505-718-3160
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-20-40526103K00000X
NM511964393373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist