Provider Demographics
NPI:1710332754
Name:BALDASSARRE, MEGAN A (PSYD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:BALDASSARRE
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 1:7627 LAKE ST STE 222
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1806
Mailing Address - Country:US
Mailing Address - Phone:708-762-9602
Mailing Address - Fax:
Practice Address - Street 1:22285 N PEPPER RD STE 401
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2542
Practice Address - Country:US
Practice Address - Phone:847-882-6604
Practice Address - Fax:847-882-6228
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009254103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist