Provider Demographics
NPI:1023626306
Name:MCENTIRE, ALEXIS ANN (MS, CGC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ANN
Last Name:MCENTIRE
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-944-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000349A170300000X
IN99099425A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300040819Medicaid