Provider Demographics
NPI:1083442883
Name:NIEDERMEYER, ALFONSE
Entity type:Individual
Prefix:
First Name:ALFONSE
Middle Name:
Last Name:NIEDERMEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4878 N ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3451
Mailing Address - Country:US
Mailing Address - Phone:908-910-9286
Mailing Address - Fax:
Practice Address - Street 1:4878 N ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3451
Practice Address - Country:US
Practice Address - Phone:908-910-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician