Healthcare Provider Details

I. General information

NPI: 1720595853
Provider Name (Legal Business Name): LESLY BERON EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 WILLE AVE
WHEELING IL
60090-3127
US

IV. Provider business mailing address

133 WILLE AVE
WHEELING IL
60090-3127
US

V. Phone/Fax

Practice location:
  • Phone: 847-520-8826
  • Fax:
Mailing address:
  • Phone: 847-520-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: