Healthcare Provider Details

I. General information

NPI: 1043671027
Provider Name (Legal Business Name): MICHAEL VANDEKREKE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 03/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3923 MERCY DRIVE SUITE F
MCHENRY IL
60050-3173
US

IV. Provider business mailing address

3923 MERCY DR SUITE F
MCHENRY IL
60050-3173
US

V. Phone/Fax

Practice location:
  • Phone: 815-344-5061
  • Fax: 815-344-5072
Mailing address:
  • Phone: 815-344-5061
  • Fax: 815-344-5072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009506
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: