Provider Demographics
NPI:1992514426
Name:EIDEM, ALEXANDRA JOY
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:JOY
Last Name:EIDEM
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 1:613 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COURTLAND
Mailing Address - State:MN
Mailing Address - Zip Code:56021-9743
Mailing Address - Country:US
Mailing Address - Phone:507-430-7377
Mailing Address - Fax:
Practice Address - Street 1:613 MAIN ST
Practice Address - Street 2:
Practice Address - City:COURTLAND
Practice Address - State:MN
Practice Address - Zip Code:56021-9743
Practice Address - Country:US
Practice Address - Phone:507-430-7377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician