Healthcare Provider Details

I. General information

NPI: 1831907898
Provider Name (Legal Business Name): MOLLY DESLANDES PSYD
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: MO DESLANDES

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 RENAISSANCE DR STE 320
PARK RIDGE IL
60068-1471
US

IV. Provider business mailing address

1440 RENAISSANCE DR STE 320
PARK RIDGE IL
60068-1471
US

V. Phone/Fax

Practice location:
  • Phone: 847-759-9110
  • Fax: 224-985-2119
Mailing address:
  • Phone: 847-759-9110
  • Fax: 224-985-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071011360
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: