Healthcare Provider Details

I. General information

NPI: 1609791888
Provider Name (Legal Business Name): ALYSIA PAVLENKO MEDINA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E OGDEN AVE STE 304
WESTMONT IL
60559-5554
US

IV. Provider business mailing address

2 ELM CREEK DR APT 508
ELMHURST IL
60126-5232
US

V. Phone/Fax

Practice location:
  • Phone: 512-368-6408
  • Fax:
Mailing address:
  • Phone: 512-368-6408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178022733
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: