Provider Demographics
NPI:1942651559
Name:AVERSA, ALEXANDRA NICOLE (MOT, OTR)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:AVERSA
Suffix:
Gender:F
Credentials:MOT, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 HALLORAN ST SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-8318
Mailing Address - Country:US
Mailing Address - Phone:772-633-7581
Mailing Address - Fax:
Practice Address - Street 1:430 HALLORAN ST SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-8318
Practice Address - Country:US
Practice Address - Phone:772-633-7581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117745225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation