Basic Information
| Provider Information | |||||||||
| NPI: | 1932851540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAROSE | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 181 GLENVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CANFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444061153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302833365 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5423 MAHONING AVE STE H | ||||||||
| Address2: | |||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445152435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306334187 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2022 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S-1601212 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | S-1601212 | 01 | OH | OHIO CSWMFT BOARD | OTHER |