NPIMap

Organization Active NPI

Pcpa Legacy, LLC

  • Clinical Psychologist
  • Northbrook, IL
National Provider Identifier
1093030132
Registry record updated Sep 6, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
071-004395 Issued in IL
Legal business name
PCPA LEGACY, LLC
Doing business as
Pcpa Legacy. LLC
Practice address
400 Skokie Blvd Ste 245
Northbrook, IL 60062-7932
Phone
(847) 630-1611
Fax
(847) 446-4673
NPI assigned
Apr 1, 2010
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 6, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Paul C Kredow, PSYD
Title
Provider/Owner
Phone
(847) 630-1611

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC0700X 071-004395 IL Primary
Clinical Child & Adolescent PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC2200X 071-004395 IL

Addresses

Primary practice location

400 Skokie Blvd Ste 245
Northbrook, IL 60062-7932

Mailing address

400 Skokie Blvd Ste 245
Northbrook, IL 60062-7932
Phone (847) 630-1611

Other names 2

  • PCPA LEGACY. LLC Doing business as
  • Primary Care Psychology Assocaites, LLC Former legal business name

National Provider Directory

National Provider Directory

Locations

1135 S Delano Ct E
Ste A201
Chicago, IL 60605
Phone (312) 926-5346

350 S Waukegan Rd
#200
Deerfield, IL 60015

1704 Maple Ave
Evanston, IL 60201
Phone (312) 694-2300

3633 W Lake Ave
Ste 245
Glenview, IL 60026

767 Park Ave W
Ste 230
Highland Park, IL 60035
Phone (847) 681-7100

2592 E Grand Ave
Lindenhurst, IL 60046
Phone (847) 295-1220

300 Center Dr
Ste 103
Vernon Hills, IL 60061
Phone (224) 381-2824

870 N Milwaukee Ave
Vernon Hills, IL 60061
Phone (847) 475-2273

572B Lincoln Ave
Winnetka, IL 60093
Phone (847) 501-4040

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1270080000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1693958400000",
    "number": "1093030132",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 SKOKIE BLVD STE 245",
            "city": "NORTHBROOK",
            "state": "IL",
            "postal_code": "600627932",
            "telephone_number": "847-630-1611",
            "fax_number": "847-446-4673"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 SKOKIE BLVD STE 245",
            "city": "NORTHBROOK",
            "state": "IL",
            "postal_code": "600627932",
            "telephone_number": "847-630-1611",
            "fax_number": "847-446-4673"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PCPA LEGACY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-04-01",
        "last_updated": "2023-09-06",
        "certification_date": "2022-10-27",
        "status": "A",
        "authorized_official_last_name": "KREDOW",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PROVIDER/OWNER",
        "authorized_official_telephone_number": "847-630-1611",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSYD"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical",
            "state": "IL",
            "license": "071-004395",
            "primary": true
        },
        {
            "code": "103TC2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "IL",
            "license": "071-004395",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PCPA LEGACY. LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Primary Care Psychology Assocaites, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Northbrook, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.