Provider Demographics
NPI:1336867522
Name:MEDIAK, ALEXA RACHELLE (LMSW)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:RACHELLE
Last Name:MEDIAK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NY
Mailing Address - Zip Code:14086-1002
Mailing Address - Country:US
Mailing Address - Phone:716-861-0361
Mailing Address - Fax:
Practice Address - Street 1:175 E 94TH ST APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2905
Practice Address - Country:US
Practice Address - Phone:917-674-3421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115250104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker