Healthcare Provider Details

I. General information

NPI: 1124355664
Provider Name (Legal Business Name): NANCY LANDRE PHD, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2604 DEMPSTER ST SUITE 510
PARK RIDGE IL
60068-8412
US

IV. Provider business mailing address

2604 DEMPSTER ST SUITE 510
PARK RIDGE IL
60068-8412
US

V. Phone/Fax

Practice location:
  • Phone: 847-291-2758
  • Fax: 815-455-4322
Mailing address:
  • Phone: 847-291-2758
  • Fax: 815-455-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071004694
License Number StateIL

VIII. Authorized Official

Name: DR. NANCY LANDRE
Title or Position: OWNER
Credential: PH.D.
Phone: 847-219-2758