Basic Information
| Provider Information | |||||||||
| NPI: | 1487760195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANDYA | ||||||||
| FirstName: | HEENA | ||||||||
| MiddleName: | DIPAK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DESAI | ||||||||
| OtherFirstName: | HEENA | ||||||||
| OtherMiddleName: | YOGENDRA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | CHILD AND ADOLESCENT BEHAVIORAL SERVICES | ||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778950 | ||||||||
| FaxNumber: | 4142663735 | ||||||||
| Practice Location | |||||||||
| Address1: | 3010 GRAND AVE | ||||||||
| Address2: | CHILD AND ADOLESCENT BEHAVIORAL SERVICES | ||||||||
| City: | WAUKEGAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473778950 | ||||||||
| FaxNumber: | 4142663735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 51660-20 | WI | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | MD00045301 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.