Provider Demographics
NPI:1588667315
Name:LEAVITT, BARRY M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:M
Last Name:LEAVITT
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 1:4801 W PETERSON AVE
Mailing Address - Street 2:STE 525
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646
Mailing Address - Country:US
Mailing Address - Phone:773-286-3100
Mailing Address - Fax:773-777-7543
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:STE 525
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646
Practice Address - Country:US
Practice Address - Phone:773-286-3100
Practice Address - Fax:773-777-7543
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
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
IL653-160Medicare ID - Type UnspecifiedPART B