=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649034604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL JOURNEYS BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2024
-----------------------------------------------------
Last Update Date | 02/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1509 W BERWYN AVE STE 204
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-8058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-989-2101
-----------------------------------------------------
Fax | 773-825-8473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2223 W HIGHLAND AVE APT 1E
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60659-2187
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-989-2101
-----------------------------------------------------
Fax | 773-825-8473
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ALEXANDER J LALLEY
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 847-989-2101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------