Healthcare Provider Details

I. General information

NPI: 1235612052
Provider Name (Legal Business Name): LESLIE GARDNER MCKEEVER PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 N WOLCOTT AVE APT 2
CHICAGO IL
60622-4940
US

IV. Provider business mailing address

928 N WOLCOTT AVE APT 2
CHICAGO IL
60622-4940
US

V. Phone/Fax

Practice location:
  • Phone: 847-372-1483
  • Fax:
Mailing address:
  • Phone: 847-372-1483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043194A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010210
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: