Provider Demographics
NPI:1417901620
Name:CHACKO, ALEXANDER (LCSW, MS, PHD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:LCSW, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E QUEENWOOD RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2949
Mailing Address - Country:US
Mailing Address - Phone:309-263-4244
Mailing Address - Fax:
Practice Address - Street 1:104 E QUEENWOOD RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-2949
Practice Address - Country:US
Practice Address - Phone:309-263-4244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL1490093991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical