Provider Demographics
NPI:1588151104
Name:SHOUP, ALEXIS M (LSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:M
Last Name:SHOUP
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1334
Mailing Address - Country:US
Mailing Address - Phone:740-592-6724
Mailing Address - Fax:740-592-6728
Practice Address - Street 1:224 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1334
Practice Address - Country:US
Practice Address - Phone:740-592-6720
Practice Address - Fax:740-592-6729
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1201194104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2314525Medicaid
OH2864002Medicaid