Healthcare Provider Details

I. General information

NPI: 1255803045
Provider Name (Legal Business Name): BERNARD J VONDERHAAR DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 W DIVISION ST
CHICAGO IL
60651-2405
US

IV. Provider business mailing address

2216 W BELMONT AVE # 2F
CHICAGO IL
60618-6421
US

V. Phone/Fax

Practice location:
  • Phone: 312-413-7425
  • Fax:
Mailing address:
  • Phone: 773-391-6703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.018283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: