Provider Demographics
NPI:1093131278
Name:FERNANDEZ, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:FERNANDEZ
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 1:2000 N LINCOLN PARK W UNIT 707
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4708
Mailing Address - Country:US
Mailing Address - Phone:702-480-9295
Mailing Address - Fax:
Practice Address - Street 1:2255 ENTERPRISE DR STE 5501
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5808
Practice Address - Country:US
Practice Address - Phone:708-965-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4306103K00000X
TX5532103K00000X
106S00000X
IL1-20-46788103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician