Provider Demographics
NPI:1902325905
Name:OWENS, VANESSA L
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:L
Last Name:OWENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S. HARVARD STREET
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181
Mailing Address - Country:US
Mailing Address - Phone:630-516-7641
Mailing Address - Fax:
Practice Address - Street 1:255 S. HARVARD STREET
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181
Practice Address - Country:US
Practice Address - Phone:630-516-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL735646103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool