Provider Demographics
NPI:1679186159
Name:WILD, ALEXANDRA (MS, BCBA)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 SHORE RD APT 322
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4620
Mailing Address - Country:US
Mailing Address - Phone:631-987-0089
Mailing Address - Fax:
Practice Address - Street 1:500 BI COUNTY BLVD STE 450
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3995
Practice Address - Country:US
Practice Address - Phone:631-388-7813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVQA483M92106Medicaid