Basic Information
Provider Information | |||||||||
NPI: | 1992152565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANIELS | ||||||||
FirstName: | ALEXANDRA | ||||||||
MiddleName: | RENE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA, BCBA, LBA, COBA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FAWCETT | ||||||||
OtherFirstName: | ALEXANDRA | ||||||||
OtherMiddleName: | RENE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA, BCBA, LBA, COBA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462686135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3173768336 | ||||||||
FaxNumber: | 7654546664 | ||||||||
Practice Location | |||||||||
Address1: | 2904 FOLTZ DR | ||||||||
Address2: |   | ||||||||
City: | EDGEWOOD | ||||||||
State: | KY | ||||||||
PostalCode: | 410172525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8597953000 | ||||||||
FaxNumber: | 7654506664 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2016 | ||||||||
LastUpdateDate: | 11/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | COBA.256 | OH | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 103K00000X | 256 | OH | N |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   | 103K00000X | 167338 | KY | Y |   | Behavioral Health & Social Service Providers | Behavioral Analyst |   |
ID Information
ID | Type | State | Issuer | Description | 1-16-21799 | 01 |   | BEHAVIOR ANALYST CERT | OTHER |