Basic Information
| Provider Information | |||||||||
| NPI: | 1497769459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DR. ALISSA WICKLUND, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 DREXEL AVE | ||||||||
| Address2: | |||||||||
| City: | LA GRANGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605255815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085889940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 333 N MICHIGAN AVE STE 1801 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606013984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123450933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WICKLUND | ||||||||
| AuthorizedOfficialFirstName: | ALISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7085889940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.