Provider Demographics
NPI:1093715088
Name:PENDARVIS, LEAH (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:
Last Name:PENDARVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N LAKE ST
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-1521
Mailing Address - Country:US
Mailing Address - Phone:847-548-9313
Mailing Address - Fax:847-548-7029
Practice Address - Street 1:11 N SLUSSER ST
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-1524
Practice Address - Country:US
Practice Address - Phone:847-548-9313
Practice Address - Fax:847-548-7029
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211534Medicare ID - Type Unspecified