Provider Demographics
NPI:1053920512
Name:BEDELL, ALYSE RENAE (PHD)
Entity type:Individual
Prefix:DR
First Name:ALYSE
Middle Name:RENAE
Last Name:BEDELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S MARYLAND AVE # MC3077
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1443
Mailing Address - Country:US
Mailing Address - Phone:773-702-2458
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-702-3858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010326103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical