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General NPI Number Information
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NPI Number | 1659197879
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Entity Type | Individual
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Provider Name | ALEXIS LYNNE PETTENGILL LSW
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Gender | Female
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 1335 W BIRCHWOOD AVE APT 403
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City | CHICAGO
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State | IL
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Zip | 60626-5907
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Country | US
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Telephone | 231-942-1462
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Fax |
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Provider Business Mailing Address
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Address Line | 899 SKOKIE BLVD STE 300
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City | NORTHBROOK
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State | IL
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Zip | 60062-4023
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Country | US
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Telephone | 224-202-6260
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 150111440
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License Number State | IL
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