Provider Demographics
NPI:1699462168
Name:DETTMER, ALEXIS J
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:J
Last Name:DETTMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5716 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-1143
Mailing Address - Country:US
Mailing Address - Phone:630-534-7428
Mailing Address - Fax:
Practice Address - Street 1:240 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4038
Practice Address - Country:US
Practice Address - Phone:163-053-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist