Provider Demographics
NPI:1720611197
Name:EDGE, ALISSA ANN (MA, LCPC)
Entity type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:ANN
Last Name:EDGE
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 N LA SALLE DR STE 275
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-3754
Mailing Address - Country:US
Mailing Address - Phone:937-477-7545
Mailing Address - Fax:
Practice Address - Street 1:1227 W SCHOOL ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1425
Practice Address - Country:US
Practice Address - Phone:937-477-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014512101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health