Healthcare Provider Details

I. General information

NPI: 1497515159
Provider Name (Legal Business Name): LONDON VANDERBILT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROHLWING RD
ELK GROVE VILLAGE IL
60007-3217
US

IV. Provider business mailing address

430 E 162ND ST # 579
SOUTH HOLLAND IL
60473-2258
US

V. Phone/Fax

Practice location:
  • Phone: 847-524-8800
  • Fax:
Mailing address:
  • Phone: 708-355-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: