Basic Information
| Provider Information | |||||||||
| NPI: | 1942438718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN ALEXANDER ISRAEL CONSULTING INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S WOODLAND AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463607189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198774954 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2009 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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| AuthorizedOfficialLastName: | FREEZE | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2199268320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 20042094A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 000000522563 | 01 | IN | ANTHEM | OTHER |