Provider Demographics
NPI:1053191643
Name:GOETTKE, ALEXIS JORDAN (BCBA)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:JORDAN
Last Name:GOETTKE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 FOUNTAIN PL UNIT A
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1652
Mailing Address - Country:US
Mailing Address - Phone:859-462-5902
Mailing Address - Fax:
Practice Address - Street 1:5522 TAYLOR MILL RD
Practice Address - Street 2:
Practice Address - City:TAYLOR MILL
Practice Address - State:KY
Practice Address - Zip Code:41015-4604
Practice Address - Country:US
Practice Address - Phone:859-317-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1-23-68563103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst