Provider Demographics
NPI:1205584570
Name:VAN AMAN CENTER FOR WELLNESS, PLLC
Entity type:Organization
Organization Name:VAN AMAN CENTER FOR WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN AMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:847-644-3672
Mailing Address - Street 1:1413 MOSS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2915
Mailing Address - Country:US
Mailing Address - Phone:847-644-3672
Mailing Address - Fax:
Practice Address - Street 1:1224 TOWANDA AVE STE 22
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7414
Practice Address - Country:US
Practice Address - Phone:847-644-3672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073066155OtherNPI TYPE 1