Provider Demographics
NPI:1497893515
Name:LYNN, LESLIE (PHD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:LYNN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 MAPLE LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1125
Mailing Address - Country:US
Mailing Address - Phone:847-272-5575
Mailing Address - Fax:847-272-5565
Practice Address - Street 1:2055 W BALMORAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-1001
Practice Address - Country:US
Practice Address - Phone:773-561-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
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
IL537440Medicare ID - Type Unspecified