Healthcare Provider Details

I. General information

NPI: 1689162901
Provider Name (Legal Business Name): REGINALD DELEON PACHECO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 MAIN ST STE D
PARK RIDGE IL
60068
US

IV. Provider business mailing address

6050 N FRANCISCO AVE APT GE
CHICAGO IL
60659-2524
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-4444
  • Fax:
Mailing address:
  • Phone: 630-408-3672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: