Provider Demographics
NPI:1790110302
Name:PRIMARY CARE PSYCHOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE PSYCHOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KREDOW
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-686-0090
Mailing Address - Street 1:465 CENTRAL AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-3045
Mailing Address - Country:US
Mailing Address - Phone:847-686-0090
Mailing Address - Fax:847-686-0090
Practice Address - Street 1:465 CENTRAL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-3045
Practice Address - Country:US
Practice Address - Phone:847-686-0090
Practice Address - Fax:847-686-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008525273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit