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General NPI Number Information
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NPI Number | 1093030132
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Entity Type | Organization
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Legal Business Name | PCPA LEGACY, LLC
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Dates
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Enumeration Date | 04/01/2010
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Last Update Date | 09/06/2023
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Provider Practice Location Address
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Address Line | 400 SKOKIE BLVD STE 245
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City | NORTHBROOK
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State | IL
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Zip | 60062-7932
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Country | US
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Telephone | 847-630-1611
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Fax | 847-446-4673
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Provider Business Mailing Address
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Address Line | 400 SKOKIE BLVD STE 245
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City | NORTHBROOK
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State | IL
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Zip | 60062-7932
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Country | US
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Telephone | 847-630-1611
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Fax | 847-446-4673
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Authorized Official
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Title or Position | PROVIDER/OWNER
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Name | DR. PAUL C KREDOW
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Credential | PSYD
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Telephone | 847-630-1611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 071-004395
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-004395
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License Number State | IL
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