Provider Demographics
NPI:1083199186
Name:MCGOUGH, ALEXIS (LSW)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:KIEFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:2400 RAVINE WAY STE 600
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-7615
Mailing Address - Country:US
Mailing Address - Phone:847-730-3042
Mailing Address - Fax:847-730-3382
Practice Address - Street 1:900 N SHORE DR STE 205
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2253
Practice Address - Country:US
Practice Address - Phone:847-730-3042
Practice Address - Fax:847-730-3382
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1800534-TRNE104100000X
OHS.1803056104100000X
IL150.109325104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1083199186Medicaid