Healthcare Provider Details

I. General information

NPI: 1629649157
Provider Name (Legal Business Name): JOHN HARDIE PHD CLINICAL PSYCHOLOGIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 REVERE DR STE G
NORTHBROOK IL
60062-8001
US

IV. Provider business mailing address

85 REVERE DR STE G
NORTHBROOK IL
60062-8001
US

V. Phone/Fax

Practice location:
  • Phone: 847-559-9343
  • Fax: 773-913-2395
Mailing address:
  • Phone: 847-559-9343
  • Fax: 773-913-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: YESENIA SERVIN
Title or Position: CREDENTIALING MANANGER
Credential: CPMSM, PESC
Phone: 708-979-9082