=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891429627
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALISSA MARIANA IRWIN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2022
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 S DAMEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-596-8387
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1912 PRAIRIE SQ APT 217
-----------------------------------------------------
City | SCHAUMBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60173-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-477-1956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071010722
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 071010722
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------