Provider Demographics
NPI:1659197879
Name:PETTENGILL, ALEXIS LYNNE (LSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LYNNE
Last Name:PETTENGILL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 SKOKIE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-4023
Mailing Address - Country:US
Mailing Address - Phone:224-202-6260
Mailing Address - Fax:
Practice Address - Street 1:1335 W BIRCHWOOD AVE APT 403
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-5907
Practice Address - Country:US
Practice Address - Phone:231-942-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150111440104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker