Provider Demographics
NPI:1720713886
Name:LAGE, ALEX
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:LAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14085 SW 168TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-8003
Mailing Address - Country:US
Mailing Address - Phone:786-300-9087
Mailing Address - Fax:
Practice Address - Street 1:14085 SW 168TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-8003
Practice Address - Country:US
Practice Address - Phone:786-300-9087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-207526103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL898568Medicaid