Healthcare Provider Details

I. General information

NPI: 1497769459
Provider Name (Legal Business Name): DR. ALISSA WICKLUND, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE STE 1801
CHICAGO IL
60601-3984
US

IV. Provider business mailing address

37 DREXEL AVE
LA GRANGE IL
60525-5815
US

V. Phone/Fax

Practice location:
  • Phone: 312-345-0933
  • Fax:
Mailing address:
  • Phone: 708-588-9940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. ALISSA WICKLUND
Title or Position: PRESIDENT
Credential: PHD
Phone: 708-588-9940