Provider Demographics
NPI:1104866946
Name:LANDRETH, EDWARD SPENCER (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:SPENCER
Last Name:LANDRETH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4709 GOLF ROAD
Mailing Address - Street 2:SUITE 1150
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1252
Mailing Address - Country:US
Mailing Address - Phone:773-213-1232
Mailing Address - Fax:
Practice Address - Street 1:4709 GOLF ROAD
Practice Address - Street 2:SUITE 1150
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1252
Practice Address - Country:US
Practice Address - Phone:773-213-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006758103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001635205OtherBCBS IL
IL0001635205OtherBCBS IL
ILQ62567Medicare UPIN