Healthcare Provider Details

I. General information

NPI: 1194339283
Provider Name (Legal Business Name): ALEXIS HERRERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 N CALIFORNIA AVE
CHICAGO IL
60659-3916
US

IV. Provider business mailing address

6050 N CALIFORNIA AVE
CHICAGO IL
60659-3916
US

V. Phone/Fax

Practice location:
  • Phone: 847-675-6093
  • Fax: 847-675-6092
Mailing address:
  • Phone: 847-675-6093
  • Fax: 847-675-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: