Provider Demographics
NPI:1629649157
Name:JOHN HARDIE PHD CLINICAL PSYCHOLOGIST LLC
Entity Type:Organization
Organization Name:JOHN HARDIE PHD CLINICAL PSYCHOLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANANGER
Authorized Official - Prefix:
Authorized Official - First Name:YESENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SERVIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPMSM, PESC
Authorized Official - Phone:708-979-9082
Mailing Address - Street 1:85 REVERE DR STE G
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-8001
Mailing Address - Country:US
Mailing Address - Phone:847-559-9343
Mailing Address - Fax:773-913-2395
Practice Address - Street 1:85 REVERE DR STE G
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-8001
Practice Address - Country:US
Practice Address - Phone:847-559-9343
Practice Address - Fax:773-913-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty