Provider Demographics
NPI:1003859554
Name:ALEXANDER, CHARLES LARSON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:LARSON
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19114 JONATHAN LN
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-4412
Mailing Address - Country:US
Mailing Address - Phone:773-457-3303
Mailing Address - Fax:708-428-4504
Practice Address - Street 1:15020 S RAVINIA AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3166
Practice Address - Country:US
Practice Address - Phone:708-873-9059
Practice Address - Fax:708-428-4504
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical