Provider Demographics
NPI:1194173989
Name:WELLER, ALEXANDRA KATHLEEN
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:KATHLEEN
Last Name:WELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 JOSLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3308
Mailing Address - Country:US
Mailing Address - Phone:616-280-1174
Mailing Address - Fax:
Practice Address - Street 1:3361 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2809
Practice Address - Country:US
Practice Address - Phone:616-826-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
MI7401000254103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician