Provider Demographics
NPI:1922771997
Name:MUSGROVE, ALEXIS D
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:D
Last Name:MUSGROVE
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 1:3221 LODWICK DR NW APT 5
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-1562
Mailing Address - Country:US
Mailing Address - Phone:412-863-8966
Mailing Address - Fax:
Practice Address - Street 1:165 E PARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2352
Practice Address - Country:US
Practice Address - Phone:330-544-8005
Practice Address - Fax:330-544-9379
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2304905101YM0800X
172V00000X, 251S00000X
OHC.2203763-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health