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General NPI Number Information
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NPI Number | 1396245155
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Entity Type | Organization
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Legal Business Name | REDEFINING RELATIONSHIPS, ACCEPTANCE, EMPOWERMENT, & LOVE, LLC
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 10/10/2021
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Provider Practice Location Address
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Address Line | 2501 CHATHAM RD STE R
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City | SPRINGFIELD
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State | IL
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Zip | 62704-4188
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Country | US
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Telephone | 773-599-3141
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Fax |
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Provider Business Mailing Address
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Address Line | 2501 CHATHAM RD STE R
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City | SPRINGFIELD
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State | IL
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Zip | 62704-4188
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Country | US
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Telephone | 773-599-3141
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST
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Name | DR. ALEXIS CLARKE
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Credential | PHD
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Telephone | 773-599-3141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071008691
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License Number State | IL
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