Healthcare Provider Details

I. General information

NPI: 1609390962
Provider Name (Legal Business Name): BETTY VANDER LAAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2017
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 DEMPSTER STREET JUNG CENTER
EVANSTON IL
60201
US

IV. Provider business mailing address

15746 CHURCH DR
SOUTH HOLLAND IL
60473-1540
US

V. Phone/Fax

Practice location:
  • Phone: 312-787-8425
  • Fax:
Mailing address:
  • Phone: 708-309-5724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.012016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: