Provider Demographics
NPI:1538799812
Name:LALLEY, ALEXANDER JACOB (PSYD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:JACOB
Last Name:LALLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 W HIGHLAND AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-2187
Mailing Address - Country:US
Mailing Address - Phone:847-989-2101
Mailing Address - Fax:
Practice Address - Street 1:1509 W BERWYN AVE STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-8057
Practice Address - Country:US
Practice Address - Phone:847-989-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical