Provider Demographics
NPI:1407613151
Name:EARLL, ALEXIS ELLEN (MS)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ELLEN
Last Name:EARLL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:ELLEN
Other - Last Name:EARLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, BCBA
Mailing Address - Street 1:523 N RACINE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7935
Mailing Address - Country:US
Mailing Address - Phone:815-530-1924
Mailing Address - Fax:
Practice Address - Street 1:424 PINE MANOR DR
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2364
Practice Address - Country:US
Practice Address - Phone:815-530-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-23-68996103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst