Provider Demographics
NPI:1265024079
Name:WULF WAXMAN, ALEXIS MARIE (LCPC)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MARIE
Last Name:WULF WAXMAN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:MARIE
Other - Last Name:WAXMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:3630 N HARLEM AVE APT 415
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-3195
Mailing Address - Country:US
Mailing Address - Phone:773-430-9396
Mailing Address - Fax:
Practice Address - Street 1:980 N MICHIGAN AVE STE 1437
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4501
Practice Address - Country:US
Practice Address - Phone:773-430-9396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013275101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional