Provider Demographics
NPI:1033825567
Name:ALTOM, ALESSANDRA
Entity Type:Individual
Prefix:
First Name:ALESSANDRA
Middle Name:
Last Name:ALTOM
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 1:1102 CHIPPEWA ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5760
Mailing Address - Country:US
Mailing Address - Phone:224-587-0552
Mailing Address - Fax:
Practice Address - Street 1:484 W BOUGHTON RD STE C
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2478
Practice Address - Country:US
Practice Address - Phone:312-858-8562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-22-63261103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty