Provider Demographics
NPI:1407453335
Name:MOUSTAKAS, ALEXANDRA NICOLE
Entity type:Individual
Prefix:MS
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:MOUSTAKAS
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 1:325 93RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-6901
Mailing Address - Country:US
Mailing Address - Phone:646-203-5901
Mailing Address - Fax:
Practice Address - Street 1:51 SAINT EDWARDS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-3184
Practice Address - Country:US
Practice Address - Phone:718-855-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030198235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty