MEDICARE: LESLIE CREA-KAMMERER PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071008168	IL
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1831494186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE CREA-KAMMERER PSYD

Provider Business Mailing Address
First Line	:	3930 N PINE GROVE AVE APT 1911
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5510
Country	:	US
Telephone Number	:	609-221-4863
Fax Number	:

Provider Business Practice Location Address
First Line	:	2835 N SHEFFIELD AVE STE 310
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-5084
Country	:	US
Telephone Number	:	773-234-0695
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	05/14/2024

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