Provider Demographics
NPI:1831494186
Name:CREA-KAMMERER, LESLIE (PSYD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:CREA-KAMMERER
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 1:3930 N PINE GROVE AVE APT 1911
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5510
Mailing Address - Country:US
Mailing Address - Phone:609-221-4863
Mailing Address - Fax:
Practice Address - Street 1:2835 N SHEFFIELD AVE STE 516
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5081
Practice Address - Country:US
Practice Address - Phone:708-716-4624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2019-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008168103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical