Provider Demographics
NPI:1225781388
Name:DERIVERA, ALEXANDRA H
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:H
Last Name:DERIVERA
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 1:1444 N FARNSWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-1640
Mailing Address - Country:US
Mailing Address - Phone:331-213-9706
Mailing Address - Fax:630-692-3126
Practice Address - Street 1:1444 N FARNSWORTH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-1640
Practice Address - Country:US
Practice Address - Phone:331-213-9706
Practice Address - Fax:630-692-3126
Is Sole Proprietor?:No
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178013288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health