Provider Demographics
NPI:1124355664
Name:NANCY LANDRE PHD, P.C.
Entity type:Organization
Organization Name:NANCY LANDRE PHD, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-219-2758
Mailing Address - Street 1:2604 DEMPSTER ST
Mailing Address - Street 2:SUITE 510
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8412
Mailing Address - Country:US
Mailing Address - Phone:847-291-2758
Mailing Address - Fax:815-455-4322
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:SUITE 510
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8412
Practice Address - Country:US
Practice Address - Phone:847-291-2758
Practice Address - Fax:815-455-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004694103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty