Provider Demographics
NPI:1255617205
Name:GRAE, ALEXIS (MC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:GRAE
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 E PIMA ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-4370
Mailing Address - Country:US
Mailing Address - Phone:520-320-1595
Mailing Address - Fax:520-320-9123
Practice Address - Street 1:5930 E PIMA ST
Practice Address - Street 2:SUITE 208
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-4370
Practice Address - Country:US
Practice Address - Phone:520-320-1595
Practice Address - Fax:520-320-9123
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-2097101Y00000X
AZLISAC-1552101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)