Provider Demographics
NPI:1861930372
Name:VANCE, ALEXIS (MS, BCBA, NYS-LBA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:VANCE
Suffix:
Gender:F
Credentials:MS, BCBA, NYS-LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 SAINT JOHNS PL APT 7
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-3818
Mailing Address - Country:US
Mailing Address - Phone:352-727-8439
Mailing Address - Fax:
Practice Address - Street 1:1366 SAINT JOHNS PL APT 7
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-3818
Practice Address - Country:US
Practice Address - Phone:352-727-8439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-03
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003188-01103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009093700Medicaid