Provider Demographics
NPI:1235612052
Name:MCKEEVER, LESLIE GARDNER (PSYD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GARDNER
Last Name:MCKEEVER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 N WOLCOTT AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4940
Mailing Address - Country:US
Mailing Address - Phone:847-372-1483
Mailing Address - Fax:
Practice Address - Street 1:928 N WOLCOTT AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4940
Practice Address - Country:US
Practice Address - Phone:847-372-1483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010210103TC0700X
IN20043194A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical