Healthcare Provider Details

I. General information

NPI: 1598630964
Provider Name (Legal Business Name): LUKE WALLENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 SHERMAN AVE
EVANSTON IL
60201-4361
US

IV. Provider business mailing address

1316 SHERMAN AVE
EVANSTON IL
60201-4361
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-9708
  • Fax:
Mailing address:
  • Phone: 847-425-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: