Basic Information
| Provider Information | |||||||||
| NPI: | 1700375748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVINE | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, OTRL | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCMULLEN | ||||||||
| OtherFirstName: | ALEXANDRA | ||||||||
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| OtherCredential: | MS, OTRL | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9192 EL DORADO AVE | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490096715 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 JOHN ST STE M-206C | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693498601 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2018 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5237 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.