Healthcare Provider Details

I. General information

NPI: 1811460223
Provider Name (Legal Business Name): LESLIE BRANKIN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 REVERE DR STE 200
NORTHBROOK IL
60062-1574
US

IV. Provider business mailing address

60 REVERE DR STE 200
NORTHBROOK IL
60062-1574
US

V. Phone/Fax

Practice location:
  • Phone: 224-406-9974
  • Fax: 224-306-1878
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.009801
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: