Provider Demographics
NPI:1386327518
Name:LAU, ALEXIS B
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:B
Last Name:LAU
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 1:301 VILLAGE DR APT 12D
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-7748
Mailing Address - Country:US
Mailing Address - Phone:605-650-8698
Mailing Address - Fax:
Practice Address - Street 1:1368 PINEY GREEN RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-4580
Practice Address - Country:US
Practice Address - Phone:910-333-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-23-290766106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician