Provider Demographics
NPI:1306221338
Name:ALI, ALICIA (PSYD)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ALI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W WASHINGTON BLVD # 272
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2203
Mailing Address - Country:US
Mailing Address - Phone:312-248-3655
Mailing Address - Fax:
Practice Address - Street 1:226 N CLINTON ST APT 321
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661
Practice Address - Country:US
Practice Address - Phone:312-248-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0000X
IL071009851103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily