Doctor Name: | DR. SANDRA LEE REINKE VENDEN |
NPI Number: | 1144414715 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PSYD |
License Number: | 71007100 |
Business Practice Address: | 420 W Grand Ave Lake Villa, IL - 600468664 |
Business Phone Number: | 8473653322 |
Business Fax Number: | |
Mailing Address: | Po Box 1088, LAKE VILLA |
State: | IL |
Postal Code: | 600461088 |
Phone Number: | 8473653322 |
Fax Number: | |
NPI Enumeration Date: | 08/28/2007 |
NPI Last Update Date: | 08/31/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 71007100 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |