Healthcare Provider Details

I. General information

NPI: 1457064974
Provider Name (Legal Business Name): ALEXANDER VIGNETTES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3976 N AVONDALE AVE
CHICAGO IL
60641-2900
US

IV. Provider business mailing address

3523 W WRIGHTWOOD AVE
CHICAGO IL
60647-1248
US

V. Phone/Fax

Practice location:
  • Phone: 888-428-7890
  • Fax:
Mailing address:
  • Phone: 312-550-3631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178018690
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: