Healthcare Provider Details

I. General information

NPI: 1033606413
Provider Name (Legal Business Name): MR. NATHAN THOMAS VENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 CENTRAL AVE
MATTESON IL
60443-1111
US

IV. Provider business mailing address

101 CENTRAL AVE
MATTESON IL
60443-1111
US

V. Phone/Fax

Practice location:
  • Phone: 708-720-6285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number765573
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: