Provider Demographics
NPI:1821560681
Name:FOTOPOULOS, ALEXANDRIA
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:FOTOPOULOS
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 1:110 COLLINS ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-2942
Mailing Address - Country:US
Mailing Address - Phone:815-727-6997
Mailing Address - Fax:815-727-6996
Practice Address - Street 1:7435 W MANITOBA DR
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-2017
Practice Address - Country:US
Practice Address - Phone:708-912-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1835966103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL103TS0200XOther62