Provider Demographics
NPI:1164065710
Name:BOOKER, ALEXANDRIA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:BOOKER
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 1:23756 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9524
Mailing Address - Country:US
Mailing Address - Phone:850-603-4990
Mailing Address - Fax:
Practice Address - Street 1:2014 LINCOLNWAY E STE 3
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6818
Practice Address - Country:US
Practice Address - Phone:239-920-3948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-23-63495103K00000X
FLRBT-19-1705-178936106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician