Provider Demographics
NPI:1881266450
Name:PELLACK, ALEXA COURTNEY
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:COURTNEY
Last Name:PELLACK
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 1:1502 SW 50TH ST APT 304
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-3459
Mailing Address - Country:US
Mailing Address - Phone:570-730-1916
Mailing Address - Fax:
Practice Address - Street 1:1502 SW 50TH ST APT 304
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-3459
Practice Address - Country:US
Practice Address - Phone:570-730-1916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL69492255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer