Provider Demographics
NPI:1104582451
Name:VAN VICKLE, KATELYN BELLE (LSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:BELLE
Last Name:VAN VICKLE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:GIBSON CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60936-2000
Mailing Address - Country:US
Mailing Address - Phone:217-784-5500
Mailing Address - Fax:217-784-4106
Practice Address - Street 1:7 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:GIBSON CITY
Practice Address - State:IL
Practice Address - Zip Code:60936-2000
Practice Address - Country:US
Practice Address - Phone:217-784-5500
Practice Address - Fax:217-784-4106
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105484104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker