=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023557816
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDRA PETROHILOS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2017
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 N GRANT ST SUITE LC
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-286-2785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 N GRANT ST SUITE LC
-----------------------------------------------------
City | HINSDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60521-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-286-2785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | MRS. ALEXANDRA PETROHILOS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 630-286-2785
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180009340
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------