Basic Information
| Provider Information | |||||||||
| NPI: | 1659590966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAVIS | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Credential: | PSY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 W WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537032637 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 454 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021513034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814858222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 31520 | CA | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 11417 | MA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 31520 | 01 | CA | PSYCHOLOGIST | OTHER |