Basic Information
| Provider Information | |||||||||
| NPI: | 1710332754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDASSARRE | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7627 LAKE ST STE 222 | ||||||||
| Address2: | |||||||||
| City: | RIVER FOREST | ||||||||
| State: | IL | ||||||||
| PostalCode: | 603051806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087629602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22285 N PEPPER RD STE 401 | ||||||||
| Address2: | |||||||||
| City: | LAKE BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600102542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478826604 | ||||||||
| FaxNumber: | 8478826228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2016 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 071009254 | IL | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.