Provider Demographics
NPI:1730535840
Name:BAKOVIC, ALEXANDRA LUCIA (ATC)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:LUCIA
Last Name:BAKOVIC
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 OLIVE ST APT 210
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6984
Mailing Address - Country:US
Mailing Address - Phone:857-272-4708
Mailing Address - Fax:
Practice Address - Street 1:2416 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3248
Practice Address - Country:US
Practice Address - Phone:203-407-3598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23402255A2300X
FLAL 43002255A2300X
CT0014262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer