Provider Demographics
NPI:1902285513
Name:ALEXANDER, KATHLEEN RAE (MS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RAE
Last Name:ALEXANDER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3702 SHATTUCK ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-8760
Mailing Address - Country:US
Mailing Address - Phone:715-965-1968
Mailing Address - Fax:
Practice Address - Street 1:N3702 SHATTUCK ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-8760
Practice Address - Country:US
Practice Address - Phone:715-965-1968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI899-58103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool