Healthcare Provider Details

I. General information

NPI: 1396046900
Provider Name (Legal Business Name): NORTH SHORE PSYCHOLOGY SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 BLACKBERRY CT
GURNEE IL
60031-5112
US

IV. Provider business mailing address

850 BLACKBERRY CT
GURNEE IL
60031-5112
US

V. Phone/Fax

Practice location:
  • Phone: 847-355-5041
  • Fax:
Mailing address:
  • Phone: 847-355-5041
  • Fax: 630-924-0462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-004337
License Number StateIL

VIII. Authorized Official

Name: ANNE HACHMEISTER-LEVIN
Title or Position: PROVIDER
Credential:
Phone: 847-355-5041