Provider Demographics
NPI:1215490651
Name:DE LEON, VANESSA RAE (LPC)
Entity type:Individual
Prefix:
First Name:VANESSA RAE
Middle Name:
Last Name:DE LEON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4933 N KEDZIE AVE APT 2W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-5026
Mailing Address - Country:US
Mailing Address - Phone:630-484-0074
Mailing Address - Fax:
Practice Address - Street 1:4933 N KEDZIE AVE APT 2W
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-5026
Practice Address - Country:US
Practice Address - Phone:630-484-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012626101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional