Provider Demographics
NPI:1629176391
Name:MINEVICH, ALEXANDER (OTR/L)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:MINEVICH
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 3RD AVE APT 18A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-0063
Mailing Address - Country:US
Mailing Address - Phone:917-227-9447
Mailing Address - Fax:770-514-8511
Practice Address - Street 1:1619 3RD AVE APT 18A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-0063
Practice Address - Country:US
Practice Address - Phone:954-789-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003641225XP0200X
NY029389225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000965643EMedicaid