Provider Demographics
NPI:1831510957
Name:CLARKE, ALEXIS (PHD)
Entity type:Individual
Prefix:DR
First Name:ALEXIS
Middle Name:
Last Name:CLARKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 CHATHAM RD STE R
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4188
Mailing Address - Country:US
Mailing Address - Phone:773-599-3141
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD STE R
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:773-599-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-16
Last Update Date:2021-10-10
Deactivation Date:2017-12-29
Deactivation Code:
Reactivation Date:2018-02-28
Provider Licenses
StateLicense IDTaxonomies
IL071008691103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist