Provider Demographics
NPI:1154861490
Name:ALFANO, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:ALFANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14121 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7493
Mailing Address - Country:US
Mailing Address - Phone:708-691-1589
Mailing Address - Fax:
Practice Address - Street 1:650 N CONVENT ST
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1320
Practice Address - Country:US
Practice Address - Phone:815-523-7268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7141157Medicaid