Provider Demographics
NPI:1386119303
Name:TATTER, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:TATTER
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 1:19766 SAGO 3
Mailing Address - Street 2:
Mailing Address - City:WARBA
Mailing Address - State:MN
Mailing Address - Zip Code:55793-1610
Mailing Address - Country:US
Mailing Address - Phone:218-256-9477
Mailing Address - Fax:
Practice Address - Street 1:2407 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:LOUISIANA
Practice Address - State:MO
Practice Address - Zip Code:63353-2503
Practice Address - Country:US
Practice Address - Phone:573-754-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA086494225X00000X
WI6247-26225X00000X
MO2018005948225X00000X
MTOTP-OT-LIC-6137225X00000X
MN105362225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist