Provider Demographics
NPI:1306903539
Name:MCCOURT, ALEXANDRA
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:MCCOURT
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 1:39293 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39293 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1060
Practice Address - Country:US
Practice Address - Phone:734-502-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010644701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI384378OtherVALUE OPTIONS PROVIDER