1295984516 NPI number — KATHY J DE VRIES M.A., L.C.P.C.

Table of content: KATHY J DE VRIES M.A., L.C.P.C. (NPI 1295984516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295984516 NPI number — KATHY J DE VRIES M.A., L.C.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE VRIES
Provider First Name:
KATHY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A., L.C.P.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295984516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9721 W. 165TH ST
Provider Second Line Business Mailing Address:
SUITE 23
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60467-4511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-846-6986
Provider Business Mailing Address Fax Number:
708-460-0300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9721 W 165TH ST
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
ORLAND PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60467-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-846-6986
Provider Business Practice Location Address Fax Number:
708-460-0300
Provider Enumeration Date:
09/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  180.007790 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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