Provider Demographics
NPI:1992357081
Name:MALLET, ALEJANDRINA MARIA (RBT)
Entity type:Individual
Prefix:MRS
First Name:ALEJANDRINA
Middle Name:MARIA
Last Name:MALLET
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W SWANSON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6844
Mailing Address - Country:US
Mailing Address - Phone:907-841-6377
Mailing Address - Fax:
Practice Address - Street 1:772 KARLUK CT
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-1407
Practice Address - Country:US
Practice Address - Phone:856-982-9294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1555769594OtherTRICARE