| Pcpa Legacy, Llc | |
|
400 Skokie Blvd Ste 245 Northbrook IL 60062-7932 | |
| (847) 630-1611 | |
| (847) 446-4673 |
| Full Name | Pcpa Legacy, Llc |
|---|---|
| Speciality | Psychologist |
| Location | 400 Skokie Blvd Ste 245, Northbrook, Illinois |
| Authorized Official Name and Position | Paul C Kredow (PROVIDER/OWNER) |
| Authorized Official Contact | 8476301611 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Pcpa Legacy, Llc 400 Skokie Blvd Ste 245 Northbrook IL 60062-7932 Ph: (847) 630-1611 | Pcpa Legacy, Llc 400 Skokie Blvd Ste 245 Northbrook IL 60062-7932 Ph: (847) 630-1611 |
| NPI Number | 1093030132 |
|---|---|
| Provider Enumeration Date | 04/01/2010 |
| Last Update Date | 09/06/2023 |
| Certification Date | 10/27/2022 |
| Medicare PECOS PAC ID | 7012174477 |
|---|---|
| Medicare Enrollment ID | O20120214000033 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1093030132 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | 071-004395 (Illinois) | Primary |
| 103TC2200X | Psychologist - Clinical Child & Adolescent | 071-004395 (Illinois) | Secondary |
| Provider Name | Laura Higdon |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1396777611 PECOS PAC ID: 0345146882 Enrollment ID: I20031208000448 |
| Provider Name | Paul C Kredow |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1871502856 PECOS PAC ID: 8224046016 Enrollment ID: I20060405000563 |
| Provider Name | Boris Todorov |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1740672963 PECOS PAC ID: 1153691589 Enrollment ID: I20170718002875 |
| Provider Name | Meryl M Pankhurst |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1407288079 PECOS PAC ID: 6002187614 Enrollment ID: I20170731003541 |
| Provider Name | Lauren J Shapiro |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1982035663 PECOS PAC ID: 6103198031 Enrollment ID: I20170828000451 |
| Provider Name | Valerie F Weed |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1255709556 PECOS PAC ID: 1658674148 Enrollment ID: I20190320000312 |
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