Provider Demographics
NPI:1982872594
Name:FRASER VASELAKOS, M DENISE (PSYD)
Entity type:Individual
Prefix:DR
First Name:M DENISE
Middle Name:
Last Name:FRASER VASELAKOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12627 W 143RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8381
Mailing Address - Country:US
Mailing Address - Phone:708-645-0798
Mailing Address - Fax:708-645-0841
Practice Address - Street 1:12627 W 143RD ST
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-8381
Practice Address - Country:US
Practice Address - Phone:708-645-0798
Practice Address - Fax:708-645-0841
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-16
Last Update Date:2008-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical