Healthcare Provider Details

I. General information

NPI: 1245714161
Provider Name (Legal Business Name): EWELINA RENATA LAKOMY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 ROUTE 83 STE 211
LONG GROVE IL
60047
US

IV. Provider business mailing address

4160 ROUTE 83 STE 211
LONG GROVE IL
60047
US

V. Phone/Fax

Practice location:
  • Phone: 847-370-2462
  • Fax: 847-890-6750
Mailing address:
  • Phone: 847-370-2462
  • Fax: 847-890-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.011150
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: