Provider Demographics
NPI:1982987020
Name:VICHNIAC, ALEXIS
Entity Type:Individual
Prefix:MRS
First Name:ALEXIS
Middle Name:
Last Name:VICHNIAC
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 1:163 ELM ST
Mailing Address - Street 2:3
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144-3110
Mailing Address - Country:US
Mailing Address - Phone:617-571-8058
Mailing Address - Fax:
Practice Address - Street 1:163 ELM ST
Practice Address - Street 2:3
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-3110
Practice Address - Country:US
Practice Address - Phone:617-571-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA442207 7335103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool