Provider Demographics
NPI:1093030132
Name:PCPA LEGACY, LLC
Entity Type:Organization
Organization Name:PCPA LEGACY, LLC
Other - Org Name:PRIMARY CARE PSYCHOLOGY ASSOCAITES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KREDOW
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-630-1611
Mailing Address - Street 1:400 SKOKIE BLVD STE 245
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-7932
Mailing Address - Country:US
Mailing Address - Phone:847-630-1611
Mailing Address - Fax:847-446-4673
Practice Address - Street 1:400 SKOKIE BLVD STE 245
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-7932
Practice Address - Country:US
Practice Address - Phone:847-630-1611
Practice Address - Fax:847-446-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004395103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty