Provider Demographics
NPI:1770174955
Name:ANDERSONVILLE BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:ANDERSONVILLE BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:J
Authorized Official - Last Name:LALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-989-2101
Mailing Address - Street 1:1509 W BERWYN AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-8058
Mailing Address - Country:US
Mailing Address - Phone:847-989-2101
Mailing Address - Fax:
Practice Address - Street 1:1509 W BERWYN AVE STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-8058
Practice Address - Country:US
Practice Address - Phone:847-989-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty