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1860 W Winchester Rd Ste 106 Libertyville IL 60048-5312 | |
| (847) 816-6335 | |
| (847) 816-6355 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 1860 W Winchester Rd Ste 106, Libertyville, Illinois |
| Authorized Official Name and Position | Lori A Smith (PRACTICE MANAGER) |
| Authorized Official Contact | 8478166441 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
1860 W Winchester Rd Ste 106 Libertyville IL 60048-5312 Ph: (847) 816-6335 | 1860 W Winchester Rd Ste 106 Libertyville IL 60048-5312 Ph: (847) 816-6335 |
| NPI Number | 1629478599 |
|---|---|
| Provider Enumeration Date | 08/28/2014 |
| Last Update Date | 01/17/2025 |
| Certification Date | 01/17/2025 |
| Medicare PECOS PAC ID | 0042432296 |
|---|---|
| Medicare Enrollment ID | O20141104000962 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629478599 | NPI | - | NPPES |
| Provider Name | Olga Geniyevna Kozlova |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1477997674 PECOS PAC ID: 5991924763 Enrollment ID: I20140910001963 |
| Provider Name | Vijayta Bansal Kapuria |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1093900771 PECOS PAC ID: 4486876638 Enrollment ID: I20141104001122 |
| Provider Name | Vibhav Bansal |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1730337569 PECOS PAC ID: 2163680851 Enrollment ID: I20141110002095 |
| Provider Name | Faya Kacos-shiu |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1194118802 PECOS PAC ID: 3173884392 Enrollment ID: I20180305002258 |
| Provider Name | Katherine M Blake |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1225304322 PECOS PAC ID: 0042524480 Enrollment ID: I20180322002510 |
| Provider Name | Zhannah Vaysman |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1689199689 PECOS PAC ID: 7810324498 Enrollment ID: I20200219002984 |
| Provider Name | Terese A Wenzel |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1710559794 PECOS PAC ID: 2769887454 Enrollment ID: I20210818001975 |
| Provider Name | Lucy Rickspoone |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1164933123 PECOS PAC ID: 8527457688 Enrollment ID: I20211110001749 |
| Provider Name | Christina Marsh |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1447781430 PECOS PAC ID: 8921344227 Enrollment ID: I20220624002006 |
| Provider Name | Erica Delgado |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1770212391 PECOS PAC ID: 1951771302 Enrollment ID: I20221230000730 |
| Provider Name | Daniel William Ross |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1538550819 PECOS PAC ID: 6709135841 Enrollment ID: I20231129000412 |
| Provider Name | Elizabeth A Hozian |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1639675739 PECOS PAC ID: 2062860836 Enrollment ID: I20231205001215 |
| Provider Name | Jennifer Laflamme |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1811576416 PECOS PAC ID: 4880042662 Enrollment ID: I20231205001264 |
| Provider Name | Allison Faye Wollert |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1164994562 PECOS PAC ID: 8224471420 Enrollment ID: I20240205002320 |
| Provider Name | Michael Moore |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1285007757 PECOS PAC ID: 7618348590 Enrollment ID: I20240301001890 |
| Provider Name | Ammara Raziuddin |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1245765148 PECOS PAC ID: 6204231228 Enrollment ID: I20240329001960 |
| Provider Name | Vesna Pepic |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1649917790 PECOS PAC ID: 9234577271 Enrollment ID: I20240507003243 |
| Provider Name | Shannon Marie Winans |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1093425985 PECOS PAC ID: 3072953520 Enrollment ID: I20240513003639 |
| Provider Name | Carolyn Ann Braverman |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1366529646 PECOS PAC ID: 9931541422 Enrollment ID: I20240529003728 |
| Provider Name | Emily L Lock |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1154667293 PECOS PAC ID: 1153632526 Enrollment ID: I20240618000425 |
| Provider Name | Aparna Pendurthi |
|---|---|
| Provider Type | Practitioner - Neurology |
| Provider Identifiers | NPI Number: 1962765230 PECOS PAC ID: 7719253913 Enrollment ID: I20240912002664 |
| Provider Name | Leonard Gilbert |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1457171092 PECOS PAC ID: 1658268339 Enrollment ID: I20241029004210 |
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