Provider Demographics
NPI:1407288079
Name:PANKHURST, MERYL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MERYL
Middle Name:
Last Name:PANKHURST
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 1:465 N CENTRAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3015
Mailing Address - Country:US
Mailing Address - Phone:847-686-0090
Mailing Address - Fax:847-686-0090
Practice Address - Street 1:465 N CENTRAL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3015
Practice Address - Country:US
Practice Address - Phone:847-686-0090
Practice Address - Fax:847-686-0090
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004395103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical