Healthcare Provider Details

I. General information

NPI: 1114840824
Provider Name (Legal Business Name): THERESA ALEXANDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 REVEREND WALTON DR
LOCKPORT IL
60441-5246
US

IV. Provider business mailing address

209 REVEREND WALTON DR
LOCKPORT IL
60441-5246
US

V. Phone/Fax

Practice location:
  • Phone: 815-814-4220
  • Fax:
Mailing address:
  • Phone: 815-814-4220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberA4258003783
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: